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COLUMBIA  UNIVERSITY       ^_ 

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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/practicaltreatis1917stim 


A  PRACTICAL  TREATISE 


FRACTURES  AND  DISLOCATIONS. 


BY 


LEWIS   A.  STIMSON,  B.A.,  M.D.,  LL.D.  (Yalen), 

PROFESSOR    OP    SURGERY    IN    CORNELL    UNIVERSITY   MEDICAL   COLLEGE,    NEW    YORK;     CONSULTING 

SURGEON   TO   NEW   YORK   AND   BELLEVUE   HOSPITALS;     CORRESPONDING 

MEMBER   OF   THE   SOCIETE   DE   CHIRURGIE    OF   PARIS. 


EIGHTH  EDITION,  REVISED  AND  ENLARGED. 


WITH   475    ILLUSTRATIONS   AND   39    PLATES    IN    MONOTINT. 


LEA    &   FEBIGER, 

NEW    YORK    AND    PHILADELPHIA. 


Entered  according  to  Act  of  Congress,  in  ihe  year  1917,  by 

LEA   &   FEBIGER, 

In  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PREFACE  TO  THE  EIGHTH  EDITION 


In  the  time  which  has  passed  since  the  pubHcation  of  the  seventh 
edition  an  increased  interest  in  the  treatment  of  fractures  has  been 
manifested  and  the  accumulated  experience  has  shown  the  relative 
merits  of  various  methods  recently  under  discussion  and  has  permitted 
the  substitution  for  their  discussion  in  the  text  of  briefer  statements 
as  to  their  availability  and  the  indications  for  their  employment. 

The  principal  changes  and  additions  made  in  this  portion  of  the  book 
have  consequently  been  in  the  matter  of  treatment,  and  a  number  of 
illustrations  have  been  added.  In  dislocations  the  largest  addition  has 
been  on  the  subject  of  the  dislocations  of  the  shoulder  in  infancy — 
birth  dislocations  and  the  posterior  subluxations.  A  section  on  sub- 
luxation of  the  great  horn  of  the  hyoid  has  been  added. 

The  war  in  Europe  has  brought  to  the  hospitals  an  enormous  number 
of  fractures  and  fixed  upon  them  the  attention  of  surgeons  to  an 
unprecedented  extent.  In  the  course  of  two  visits  to  France  I  was 
able  to  visit  many  hospitals,  see  much  of  this  work,  and  note  the 
various  methods.  It  was  interesting  to  see  the  influence  of  the  example 
of  some  of  the  American  surgeons  in  introducing  or  extending  the  use 
of  some  methods,  especially  of  suspension  in  fractures  of  the  thigh  and 
in  compound  fractures  of  other  bones  to  control  inflammation  and 
facilitate  dressing.  Many  interesting  details  have  been  noted  in  the 
revision. 

I  hope  that  the  book  in  its  formulation  of  principles  and  indication 
of  choice  of  methods  will  be  a  safe  guide  for  the  practitioner  and  student. 

L.  A.  S. 

277  Lexington  Avenue, 
New  York,  1917. 


(iii) 


CONTENTS. 


FRACTURES. 


CHAPTEE   I. 

INTRODUCTION. 

PAGE, 

Definitions,  statistics,  influences  of  sex,  age,  and  season ig 

CHAPTEE  II. 

PATHOLOGY. 

A.  The  bone  ;  varieties  of  fracture 22 

1.  Incomplete  fractures 23 

(a)  Fissures •    • 23 

(6)  True  incomplete,  green-stick  ;  infraction 24 

(c)  Depressions •    •    .    .    .  24 

(d)  Separation  of  a  splinter  or  apophysis 24 

2.  Complete  fractures  ;  subdivided  according  to 25 

(a)  Direction  and  character  of  the  line  of  fracture 25 

(6)  The  seat  of  fracture .'   .    .  29 

Separation  of  epiphysis 29 

(c)  Intra-articular 31 

3.  Multiple  fractures 31 

4.  Compound  fractures 32 

5.  Gunshot  fractures 33 

Displacements 37 

B.  The  soft  parts 39 

CHAPTEE   III. 

ETIOLOGY. 

Predisposing  causes    .... 41 

External,  normal,  interstitial  atrophy 41 

Inherited  liability 42 

Determining  causes 42 

External  violence,  direct  or  indirect 42 

Muscular  action  .    .  , 43 

Spontaneous  and  pathological  fractures  .    .    .  ' , ,    .  47 

General  diseases      47 

Diseases  of  nerve  centres 43 

Kachitis,  syphilis,   rheumatism       49 

Cancer  and  sarcoma 5q 

Cysts,  osteomyelitis 5I 

Intra-uterine,  and  during  delivery 5I 

CHAPTEE   IV. 

EARLY   SYMPTOMS   AND   DIAGNOSIS. 

Objective  signs 53 

Deformity  (normal  asymmetry) 53 

Abnormal  moljility 54 

Crepitus 55 

Roentgen  rays 5g 

Subjective  or  rational  symptoms 57 

Loss  of  function ;  pain 57 

History 57 


VI  CONTENTS. 

CHAPTER  V. 

REPAIR   OF   FRACTURES   AXD    CLIXICAL   COURSE.  p^Qj, 

Anatomo-pathological  processes 59 

The  callus 59 

In  compound  fracture 63 

In  short  and  flat  bones 64 

At  the  epiphyseal  Une 65 

Clinical  course 66 

CHAPTER  VI. 

COMPLICATIONS   AND   REMOTE    CONSEQUENCES. 

Early  local  complications 70 

Skin 70 

Bloodvessels 71 

Gangrene.     Degeneration  of  muscles 72 

Suppuration 73 

Early  general  complications 73 

Septicaemia .  73 

Gas  bacillus  infection;  fat  embolism 74 

Delirium  tremens,  tetanus 75 

Pneumonia 76 

Late  local  complications 76 

Excessive  or  painful  callus 76 

Development  of  a  tumor ,      .  77 

Injury  of  a  nerve 78 

Weakness  of  callus 79 

Arrest  or  exaggeration  of  growth 79 

Stiffness  of  the  joints 79 

Atrophy 80 

Thrombosis  and  emboUsm;  arteries 81 

CHAPTER  VII. 

TREATMENT. 

Reduction 83 

Retention 90 

Temporarj^  and  removable  dressings 92 

Wooden  splints        . 92 

Metal  splints;  Volkmann's  spUnt 94 

Gutters  of  galvanized  wire  or  tin 94 

Anterior  .suspended  splints 95 

Moulded  splints 97 

Suspension  and  elevation 100 

Permanent  or  final  dressings 103 

Encasement  in  plaster 103 

Traction,  Buck's  extension 105 

Hodgen's  splint,  long  side  splint 107 

Combined  suspension  and  traction 108 

Vertical  suspension 109 

Double  inchned  plane 110 

Direct  fixation Ill 

Removal  of  permanent  dressing 118 

Massage 118 

Ambulator}'  treatment 119 

Management  of  the  joints 121 

Compound  fractures 123 

Bj'  indirect  violence 123 

By  direct  violence 124 

Gunshot  fractures '  .  126 

Amputation 127 

Compound  articular  fractures 128 

General  treatment 129 

CHAPTER  VIII. 

DELAYED    UNION,    FAILURE    OF    UNION,    FAULTY   UNION. 

Delayed  union;  failure  of  union 130 

Pathology 131 

Etiology 131 


COXTENTS.  Vii 

PAGE 

Delayed  union  :  symptoms      I33 

Treatment I34 

Faulty  or  vicious  union 136 

Treatment 136 

CHAPTER   IX. 

GENERAL   PROGNOSIS 138 

CHAPTER    X. 

FRACTURES   OF   THE  SKULL. 

Mechanism  and  pathology I43 

Exceptional  forms 148 

Internal  table I49 

Injuries  of  brain 150 

Pathological  and  reparative  processes I5I 

Symptoms,  diagnosis,  and  treatment 152 

Circumscribed  fractures  of  the  vault I53 

Fissured  fractures  with  generalized  brain  injury I55 

Internal  table jgg 

Rupture  of  the  middle  meningeal  artery 158 

Perforating  fractures  of  the  base 160 

Summary 160 

CHAPTER    XI. 

FRACTURES   OF  THE   VERTEBRA. 

Pathology .163 

Hfematomyelia      166 

Etiology 166 

Symptoms  and  diagnosis 167 

Atlas  and  axis 168 

Lower  five  cervical  and  first  two  dorsal 170 

Lower  dorsal  and  first  two  lumbar 172 

Lower  three  lumbar 173 

Course  and  termination 173 

Treatment 176 

CHAPTER    XII. 

FRACTURES  OF  THE  BONES  OF  THE  FACE. 

1-  Nose , 180 

2.  Malar  bone  and  zygoma 182 

3.  Superior  maxilla     .    •    •    • 184 

4.  Inferior  maxilla 187 

CHAPTER   XIII. 

FRACTURES   OF   THE   HYOID   BONE I95 

CHAPTER   XIV. 

FRACTURES   OF    THE   LARYNX    AND   TRACHEA jgy 

CHAPTER  XV. 

FRACTURES   OF   THE   STERNUM 199 

CHAPTER  XVI. 

FRACTURES  OF    THE   RIBS   AND  THEIR    CARTILAGES 

The  ribs 205 

The  costal  cartilages 210 


vm  -  CONTENTS. 

CHAPTER   XVII. 

FRACTURES   OF   THE   CLAVICLE.  p^qb 

Pathology • 214 

1.  Middle  third 215 

2.  Outer  third 216 

3.  Inner  third  .    . 217 

Multiple  fractures.     Complications 218 

Etiology 220 

Symptoms  and  course 221 

Simultaneous  fractures  of  both  clavicles  223 

Treatment 223 

CHAPTER   XVIII. 

FRACTURES   OF   THE  SCAPULA. 

1.  Of  the  body  of  the  scapula 230 

2.  Of  the  inferior  angle 233 

3.  Of  the  upper  angle 233 

4.  Of  the  spine 234 

5.  Of  the  acromion 234 

6.  Of  the  coracoid  process 235 

7.  Of  the  neck 236 

8.  Of  the  glenoid  cavity 240 

CHAPTER   XIX. 

FRACTURES   OF   THE   HUMERUS. 

1.  Fractures  of  the  upper  end  of  the  humerus 241 

A.  Fractures  of  the  head ;  ."    ■    *  ^^^ 

B.  Fractures  of  the  anatomical  neck  and  fracture  through  the  tuberosities  .    .  242 

C.  Fractures  of  the  tuberosities 246 

D.  Separation  of  the  epiphysis 248 

E.  Fracture  of  the  surgical  neck 252 

Symptoms 255 

Diagnosis 256 

Prognosis,  treatment 257 

2.  Fractures  of  the  shaft  of  the  humerus 260 

3.  Fractures  of  the  lower  end  of  the  humerus 266 

A.  Fractures  above  the  condyles — supracondyloid 269 

B.  Fractures  of  the  internal  epicondyle 280 

C.  Fractures  of  the  external  epicondyle '■  282 

D.  Fractures  of  the  internal  condyle •  282 

E.  Fractures  of  the  external  condyle 284 

F.  Intercondyloid,  T-shaped  or  Y-shaped  fractures 288 

G.  Separation  of  the  epiphysis 289 

H.  Fractures  of  the  articular  process 290 

Of  the  capitellum -291 

Of  the  trochlea •••••••    292 

Diagnosis 293 

Treatment      294 

Prognosis 294 

CHAPTER  XX. 

FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 

1.  In  the  vicinity  of  the  elbow-joint 296 

A.  Olecranon 296 

Separation  of  the  epiphysis 303 

B.  Coronoid  process 304 

C.  Of  the  head  of  the  radius 306 

D.  Of  the  neck  of  the  radius 309 

2.  Fractures  of  the  shaft 310 

A.  Fractures  of  the  shafts  of  both  bones 310 

B.  Of  the  shaft  of  the  ulna 317 

C.  Of  the  shaft  of  the  radius 319 

3.  Fractures  in  the  vicinity  of  the  wrist 320 


CONTENTS.  IX 

PAGE 

A.  Fractures  of  the  radius.     CoUes's  fracture 320 

Cause 327 

Symptoms *      "      '      "      "  ??q 

Diagnosis '^■^^ 

Course  and  prognosis 329 

Treatment 330 

B.  Fractures  at  the  wrist  other  than  CoUes's 332 

CHAPTER   XXI. 

FRACTURES  OF  THE  CARPUS  AND  HAND. 

1.  Fractures  of  the  carpal  bones •    •  335 

2.  Fractures  of  the  metacarpal  bones •    •  342 

3.  Fractures  of  the  phalanges 344 

4.  Fractures  of  the  sesamoid  bones  of  the  thumb 345 

CHAPTER   XXII. 

FRACTURES   OF   THE   PELVIS. 

1.  Fractures  of  the  ring  of  the  pelvis  _ 346 

Separation  of  the  symphysis  pubis 347 

Separation  in  front  and  behind  .    .    •        _. 348 

Separation  of  the  sacro-iliac  synchondrosis      348 

Separation  of  all  three  joints 348 

Fracture  of  the  pubic  portion  of  the  pelvic  ring 349 

Fracture  of  the  lateral  portion 349 

Course,  diagnosis,  treatment 351 

2.  Radiating  fracture  and  fracture  of  the  floor  of  the  acetabulum 352 

3.  Transverse  fracture  of  the  sacrum •  354 

4.  Fracture  of  the  coccyx 355 

5.  Fracture  of  the  ilium 356 

6.  Fracture  of  the  ischium 357 

7.  Fracture  of  the  pubis 358 

8.  Fracture  of  the  rim  of  the  acetabulum .       ...  358 

CHAPTER  XXIII. 

FRACTURES   OF   THE   FEMUR. 

1.  Fractures  at  the  upper  end  of  the  femur 361 

A.  Fractures  of  the  head  of  the  femur 361 

B.  Fracture  of  the  neck  of  the  femur 361 

Causes 365 

Pathology 366 

(a)   Fractures  through  the  neck 366 

(6)  Separation  of  the  epiphysis ■. 368 

(c)  Fractures  at  the  base  of  the  neck • 370 

Repair 375 

Symptoms 380 

Diagnosis 384 

Prognosis 386 

Treatment      388 

C.  Fractures  through  tiie  trochanter  and  neck 394 

D.  Fracture  of  the  great  trochanter 397 

E.  Fracture  of  the  trochanter  minor 398 

2.  Fractures  of  the  shaft  of  the  femur 398 

3.  Fractures  of  the  lower  end  of  the  femur 410 

A.  Intercondyloid  fractures 410 

B.  Separation  of  the  epiphysis 413 

C.  Fracture  of  either  condyle 416 

D.  Fracture  of  the  internal  epicondyle 418 

E.  Fracture  of  the  external  tuberosity 419 

CHAPTER     XXIV. 

FRACTURES  OF  THE  PATELLA. 

Cause 420 

Pathology 421 

Symptoms 423 

Course  and  termination 424 


X  CONTENTS. 

PAGE 

Treatment 426 

Non-operative 428 

Operative        .      .    _ 431 

For  relief  of  disability 436 

For  rupture  of  bond  (refracture) 437 

CHAPTER  XXV. 

FRACTrRES    OF   THE    BOXES    OF   THE    LEG. 

1.  fractures  of  the  upper  end 438 

Separation  of  the  epiphysis     .  _ 442 

Fracture  of  the  spine  of  the  tibia 443 

Avulsion  of  the  tubercle  of  tlie  tibia 443 

'2.   Fractures  of  the  shaft 444 

3.  Fractures  at  the  lower  end  of  the  leg 447 

A.  Comminuted  fracture  of  the  tibia 448 

B.  Supramalleolar  fracture 448 

C.  Separation  of  the  epiphysis  of  the  tibia 449 

D.  Fractures  by  everaon  and  abduction,  Pott's 450 

E.  Fractures  of  the  malleoli  by  inversion 463 

F.  Of  the  posterior  portion  of  articular  surface 466 

G.  Of  the  anterior  portion  of  the  articular  surface 466 

4.  Fractures  of  the  fibula , 468 

A.  Of  the  upper  end 468 

B.  Of  the  shaft 469 

C.  Separation  of  lower  epiphysis , 469 

CHAPTEE    XXVI. 

FKACTrKES   OF   THE   BOXES   OF   THE  FOOT. 

1.  Of  the  astragalus     .    •  _ 470 

Of  processus  posticus 471 

2.  Of  the  calcaneum • 471 

Of  the  sustentaculum 474 

Bv  muscular  action • 4/o 

3.  Of  the  scaphoid 476 

4.  Of  the  cuboid • 477 

5.  Of  the  first  cuneiform 478 

6.  Of  the  second  cuneiform      478 

7.  Fractures  of  the  metatarsal  bones 478 

8.  Fractures  of  the  phalanges 479 

9.  Fracture  of  the  sesamoid  of  the  great  toe  ....    , 479 


DISLOCATIONS. 


CHAPTER     XXVII. 

GEXERALITIES. 

Definitions *    483 

Statistics 480 

CHAPTER   XXVIII. 

ETIOLOGY   AND   MECHANISM. 

A.  Predisposing  causes 488 

B.  Immediate  or  determining  causes '    ' 489 

C.  Recurrent  or  liabitual  dislocations 490 


CONTENTS.  xi 
CHAPTER    XXIX. 

PATHOLOGICAL    ANATOMY  IN    RECENT   DISLOCATIONS ;     COMPLICATIONS  ;     PROCESS   OF 

REPAIR    AFTER    REDUCTION. 

PAGE 

Pathological  anatomy 492 

Complications 493 

Bones 493 

Bloodvessels 494 

Nerves .  49Q 

Viscera 499 

Soft  parts  and  integument 499 

Repair 5OO 

CHAPTER   XXX. 

PATHOLOGY   OF   UNREDUCED    (anCIENT)    DISLOCATIONS 503 

CHAPTER  XXXI. 

SYMPTOMS   AND  DIAGNOSIS. 

Objective  signs 508 

Deformity  . • 5O8 

Loss  of  mobility 5IO 

Crepitus 5II 

Subjective  symptoms 5II 

Pain 511 

Loss  of  function  ;  history 5II 

CHAPTER   XXXII. 

COURSE   AND   PROGNOSIS 513 

CHAPTER  XXXIII. 

TREATMENT. 

Spontaneous  reduction 515 

Obstacles  to  reduction 515 

Anaesthesia 517 

Methods  of  reduction 5I8 

Old  dislocations 523 

After-treatment 525 

Habitual  dislocation 526 

CHAPTER  XXXIV. 

ACCIDENTS   THAT    MAY   BE   CAUSED   BY   ATTEMPTS   TO   REDUCE   A   DISLOCATION  . 

Integument 528 

Emphysema  of  the  cellular  tissue 528 

Rupture  of  the  muscles 529 

Avulsion  of  a  portion  of  a  limb 529 

Injuries  of  the  main  bloodvessels 529 

Injuries  to  nerves 535 

Fracture 537 

Inflammation,  suppuration,  gangrene 538 

Persistent  oedema 539 

Syncope  and  sudden  or  early  death  ;  fat  embolism 540 

CHAPTER    XXXV. 

CONGENITAL    DISLOCATIONS. 

Statistics 54I 

Etiology 542 

Pathology  (hip) 546 


xii  CONTENTS. 

PAGE 

Symptoms  and  diagnosis .    .    „ 549 

Prognosis 55I 

Treatment " 55]^ 

CHAPTEE    XXXVI. 

SPONTANEOUS   DISLOCATIONS 

By  distention cc^ 

Paralytic    .    .    .  ' ^g^ 

Voluntary ^^g 

By  destruction  ;  by  deformity g^g 

CHAPTEE   XXXVII. 

DISLOCATIONS  OF   THE  LOWER  JAW. 

Backward ,   .  557 

Backward  with  fracture 557 

Upward 558 

Outward 558 

Forward ,   »    ,   .    .    »   .    .  558 

Pathology , 559 

Symptoms 561 

Prognosis .    .    , 561 

Treatment ,    »    .    .    .    .    .  561 

Pathological 563 

Congenital 563 

Subluxation  of  the  greater  cornu  of  hyoid  bone 564 

CHAPTEE  XXXVIII. 

DISLOCATIONS   OF   THE   VERTEBRA  AND   OF   THE   OCCIPUT  FROM   THE   ATLAS 

Classification  and  pathology 566 

Secondary  changes - • 571 

Etiology 572 

Symptoms  and  diagnosis 572 

Prognosis 574 

Treatment 575 

Dislocations  of  the  occiput 576 

Dislocations  of  the  atlas o   .  578 

Dislocations  of  the  lower  six  cervical  vertebrce  ................  581 

Dislocations  of  the  dorsal  vertebra? 588 

Dislocations  of  the  lumbar  vertebrae 0    » 589 

CHAPTEE  XXXIX. 

DISLOCATIONS   OF   THE  STERNUM. 

Of  the  body  from  the  manubrium 592 

Of  the  ensiform  process ...,...<,.  596 

CHAPTEE    XL. 

DISLOCATIONS   OF   THE   RIBS   AND  COSTAL   CARTILAGES. 

Of  the  head  of  the  rib 597 

Of  the  ribs  from  the  costal  cartilages 598 

Of  the  costal  cartilages  from  the  sternum 599 

Of  one  cartilage  from  another 601 

CHAPTEE    XLI. 

DISLOCATIONS   OF  THE  CLAVICLE. 

1.  Of  the  Sternal  end  .    . ^^? 

Forward 603 

Backward 606 

Upward 608 


CONTENTS.  xiii 

PAGE 

2.  Of  the  acrominl  end • 610 

Siipra-acromial , gj^j 

Subacromial .                qXQ 

Subcoracoid 6X9 

3.  Simultaneous  of  both  ends 619 

CHAPTER    XLII. 

DISLOCATIONS    OF   THE   SHOULDER. 

Anatomy 621 

Statistics 625 

Classification 626 

Anterior  (and  downward)  dislocations 631 

1.  Subcoracoid 632 

Pathology 634 

Symptoms  and  diagnosis 637 

2.  Intracoracoid 639 

Treatment  of  anterior  dislocations 641 

Direct  reposition  ;  traction  downward  and  outward 643 

Traction  upward 645 

Traction  with  leverage 646 

Heel  in  the  axilla 646 

Forcible  traction 647 

Manipulation 647 

After-treatment 651 

CHAPTER   XLIII. 

DISLOCATIONS  OF  THE  SHOULDER — Continued. 

Downward  dislocations 653 

1.  Subglenoid 653 

Symptoms  ;  treatment 656 

2.  Luxatio  erecta 656 

3.  Subtricipital  dislocation         657 

Posterior  dislocations  (subacromial,  subspinous) 658 

Symptoms 662 

Diagnosis 663 

Prognosis 664 

Treatment 664 

Upward  dislocations  (supraglenoid,  supracoracoid) 664 

CHAPTER  XLIV. 
DISLOCATIONS  OF  THE  SHOULDER — Continued. 

Associated  injuries  and  complications 669 

Laceration  of  muscles 669 

Fractures 670 

Nerves 673 

Vessels 674 

Chest.     Compound 675 

Simultaneous  of  both  shoulders 675 

Prognosis  and  after-treatment 676 

Habitual  dislocation 678 

Treatment  of  old  dislocations 683 

Birth  dislocations 685 

Congenital  dislocations 686 

Posterior  subluxations  of  infancy .  690 

Dislocations  due  to  paralysis .  092 

Pathological  dislocations  and  subluxations 692 

CHAPTER  XLV. 

DISLOCATIONS    OF   THE    ELBOW. 

Anatomy 695 

Frequency.     Classification 697 


xiv  CONTENTS. 

PAGE 

Dislocations  of  the  forearm  backward 698 

Mechanism 698 

Pathology -700 

Complications 702 

Symptoms 703 

Diagnosis 704 

Prognosis 705 

Treatment 706 

Lateral  dislocations 710 

Incomplete  lateral 711 

A.  Inward 712 

B.  Outward 714 

Complete  outward 717 

Forwai'd  dislocations 721 

Divergent  dislocations  of  the  radius  and  ulna 727 

A.  Antero-posterior 727 

B.  Transverse 729 

CHAPTEE   XLVI. 

DISLOCATIONS  OF  THE  ELBOW — Continued. 

Dislocation  of  the  ulna  alone '30 

1.  Backward '31 

2.  Inward 734 

3.  Forward • 734 

Dislocation  of  the  radius  alone '34 

1.  Backward  ....            735 

2.  Outward 740 

3.  Forward _ ■ 742 

4.  By  elongation,  or  subluxation  in  children 746 

Dislocation  of  the  head  of  the  radius  with  fracture  of  the  ulna 751 

CHAPTER   XLVII. 

DISLOCATIONS  OF  THE  ELBOW — Continued. 

Treatment  of  old  dislocations •  753 

Congenital  and  pathological  dislocations 759 

CHAPTER   XLVIII. 

DISLOCATIONS  AT   THE  WRIST. 

Dislocations  of  the  lower  radio-ulnar  joint 763 

Backward  .    , 763 

Forward 764 

Inward  and  downward 765 

Dislocations  of  the  radio-carpal  joint 765 

Backward 767 

Forward ' 769 

Outward 771 

Pathological  ;  subluxation  forward 771 

Congenital 775 

Dislocations  of  the  carpal  bones • 776 

Medio-carpal 777 

Midcarpal  fracture — dislocation 778 

Isolated  dislocations  of  the  carpal  bones 782 

Scaphoid 782 

Semilunar  . 783 

Unciform :  pisiform 785 

Os  magnum   •    •    •_ 785 

Trapezoid 786 

Trapezium 787 

Os  magnum  and  trapezoid      787 

Carpo-metacarpal  dislocations 787 


CONTENTS.  XV 

CHAPTEE   XLIX. 

DISLOCATIONS   OF   THE   THUMB   AND   FINGERS. 

PAGE 

Proximal  phalanx  of  thumb 793 

Anatomy 793 

Backward 794 

Forward 798 

Lateral 799 

]\Ietacarpo-phalangeal  of  the  fingers 799 

Backward 800 

Forward 801 

Dislocations  of  the  middle  phalanges 801 

Backward 801 

Forward 801 

Lateral 802 

Dislocations  of  the  distal  phalanges 802 

Backward 802 

Forward 803 

Lateral 803 

CHAPTER    L. 

DISLOCATIONS  OF   THE   PELVIS  AND   OF   THE   COCCYX. 

Dislocations  of  the  pelvis 804 

Dislocations  of  the  coccyx 804 

Forward 805 

Backward 806 

Lateral 806 


CHAPTER   LI. 

DISLOCATIONS    OF   THE   HIP. 

Anatomy 807 

Statistics 810 

Simultaneous  dislocation  of  both  hips 811 

Compound  dislocations 811 

Classification 813 

Backward  dislocations .       817 

1.  Dorsal  dislocations 818 

Causes 818 

Pathology 819 

Symptoms 822 

Diagnosis 825 

2.  Everted  dorsal  dislocations 825 

Pathology 827 

Anterior  oblique 828 

Symptoms 828 

Treatment  of  backward  dislocations 829 


CHAPTEE  LII. 

DISLOCATIONS  OF  THE  HIP — Continued. 

Dislocations  downward  and  inward 834 

Obturator  or  thyroid  dislocations 834 

Cause 834 

Pathology 835 

Symptoms 836 

Treatment 837 

Perineal  dislocations 839 

Dislocations  upward  and  forward,  and  inward  and  forward  (suprapubic) 840 

Iliopectineal ;  pubic;  intrapelvic 840 


xvi  CONTENTS. 

PAGE 

Dislocations,  iliopectineal.     Pathology 841 

Symptoms 843 

Treatment 844 

Dislocations  directly  upward  (subspinous;  supracotyloid) 845 

Dislocations  directly  downward  (infracotyloid) 849 


CHAPTEE   LIU. 

DISLOCATIONS  OF  THE  HIP — Continued. 

Complications   ....        852 

Muscles.     Bloodvessels .  852 

Nerves.     Fractures 853 

Simultaneous  dislocation  of  both  hips 855 

Accidents  caused  by  attempts  to  reduce 856 

Prognosis  and  after-treatment 857 

Habitual  dislocations 857 

Treatment  of  old  unreduced  dislocations 859 

Congenital  dislocations 862 

Spontaneous  or  pathological  dislocations 862 

CHAPTER   LIV. 

DISLOCATIONS   OF   THE   KNEE. 

Anatomy 865 

Statistics 866 

Dislocations  forward 867 

Dislocations  backward ...        871 

Lateral  dislocations 874 

1.  Outward  dislocations 874 

2.  Inward  dislocations 877 

Antero-lateral  dislocations 877 

Dislocations  by  rotation 878 

Outward 878 

Inward ..."  880 

Dislocation  of  the  semilunar  cartilages    .     .    .     • 881 

Congenital  dislocations 884 

Spontaneous  or  pathological  dislocations 886 


CHAPTEE   LV. 

DISLOCATIONS  OF   THE  PATELLA. 

General  considerations    ....  887 

Outward  dislocations 890 

1.  Complete 890 

2.  Incomplete 893 

3.  Outward  edgewise,  or  vertical 894 

Inward  dislocations 895 

Inward  edgewise,  or  vertical 896 

Complete  reversal 896 

Downward  with  rotation 897 

Congenital  dislocations 898 

Habitual  or  pathological  dislocations 899 


CHAPTEE   LVI. 

DISLOCATIONS   OF   THE   FIBULA. 

Dislocations  of  the  upper  end ...  901 

1.  Forward .  901 

2.  Backward 902 

3.  Upward 902. 


CONTENTS.  xvii 


Dislocations  of  the  lower  end g03 

Spontaneous  or  pathological  dislocations 9Q3 


CHAPTER     LVII. 

DISLOCATIONS    AT   OR   NEAR    THE   ANKLE. 

Anatomy 905 

Dislocations  of  the  foot.     Tibio-tarsal  dislocations 906 

1.  Dislocations  backward 906 

2.  Dislocations  forward 908 

3.  Dislocations  inward  .   .        909 

4.  Dislocations  outward 910 

5.  Dislocations  upward 911 

6.  Compound  and  com |)licated  dislocations 911 

Subastragaloid  dislocations 912 

1.  Dislocations  inward  or  inward  and  backward 912 

2.  Dislocations  outward 914 

3.  Dislocations  backward    .    .    .   - , .  915 

4.  Dislocations  forward 916 

Diagnosis 917 

Treatment 918 

Total  dislocations  of  the  astragalus ,    .    .    .    ,  919 

1.  Forward 920 

2.  Outward  and  forward 920 

3.  Inward  and  forward 920 

4.  Inward 921 

5.  Backward 921 

6.  By  rotation 922 

Treatment 925 

Medio-tarsal  dislocation ,    .    .    .  927 

Congenital  dislocations  of  the  ankle-joint 928 

CHAPTER   LVIII. 

DISLOCATIONS   OF   THE   TARSAL    AND   METATARSAL   BONES   AND   OF  THE  TOES. 

Calcaneum 929 

Scaphoid 929 

Cuboid 930 

Cuneiform  bones 930 

Of  the  metatarsal  bones  from  the  tarsus  and  from  one  another 931 

Subluxation  of  the  head  of  a  metatarsal  bone 932 

Dislocations  of  the  toes 933 

1.  Metatarso-phalangeal  dislocations 933 

Of  the  great  toe~ 933 

Of  the  other  toes 933 

2.  Dislocations  of  the  phalanges 933 


LIST  OF  PLATES. 


I. — Recent  gunshot  fracture  of  carpus  and  radius 34 

IL — Fig.  1.  Periosteal    bridge;    fracture  of  forearm.     Fig.  2.  Periosteal 

bridge;  humerus;  two  years  after  injury 40 

III. — Same  as  Plate  II.,  Fig.  2;  injury  recent 40 

IV. — Lane's  plate.     Failure  of  union ;    absorption  of  bone,   loosening  of 

screws        n^ 

Y. — Fracture  of  hyoid  bone - 195 

VI. — Fracture  of  surgical  neck  of  humerus  in  a  child 252 

VII. — Fig.  1.  Old  supracondyloid  fracture  of  humerus;  cubitus  varus. 
Fig.  2.  Cubitus  varus,  three  years  after  a  low  partial  supracondy- 
loid fracture 274 

VIII. — Fig.  1.  Fracture  of  lower  end  of  humerus.     Fig.  2.  Supracondyloid 

fracture  by  extension 274 

IX. — Fig.  1.  Supracondyloid  fracture  of  humerus  by  extension.     Fig.  2. 

Supracondyloid  fracture  of  humerus  by  flexion 274 

X. — Figs.  1  and  2    Supracondyloid  fracture 274 

XL — Fracture  of  internal  condyle  of  humerus,  in  an  adult 282 

XII. — Fig.  1.  Fracture  of  internal  epicondyle  of  humerus.    Fig.  2.  Fracture 

of  external  condyle  of  humerus 282 

XIII. — Fig.  1.  Fracture  of  radius ;  marked  angular  displacement.     Fig.  2. 

Eecent  Colles's  fracture  in  a  boy  12  years  old 324 

XIV. — Fig.  1.  Recent  Colles's  fracture ;  male,  22  years  old.     Fig.  2.  Old 

Colles's  fracture 324 

XV. — Fig.  1.  Recent  Colles's  fracture,   comminuted ;  male.   45  years  pld. 

Fig.  2.  Recent  Colles's  fracture,  comminuted  ;  male,  40  years  old    324 
XVI. — Fig.  1.  Recent  Colles's  fracture;  male,  26  years  old.     Fig.  2.  Same 

as  Fig.  1,  side  view       324 

XVII.— Fig.  1.  Same  as  Plate  XVI.,  after  reduction.     Fig.  2.  Recent  Colles's 

fracture  ;  male,  56  years  old 324 

XVIII. — Fig.  1.  Recent  Colles's  fracture;  male,  22  years  old.     Fig.  2.  Com- 
minuted Colles's  fracture ' .....    324 

XIX.— Fig.  l._  Colles's  fracture  at  12  years;  arrest  of  growth.     Fig.  2.  Sepa- 
ration of  radial  epiphysis;  boy  15  years  old 324 

XX. — Fig.    1.    iS^rmal   wrist;  adult   male.     Fig.    2.    Normal   wrist;  adult 

female,  fracture  of  third  metacarpal 324 

XXL— Fracture  of  acetabulimi  and  displacement  of  femur  inward 354 

XXIL— Fig.  1.  Fracture  of  neck  of  fenuir.     Fig.  2.   The  same  after  traction  .    390 
XXIII. — Fig.  1.  Fractui'e  of  internal  epicondyle  of  the  femur.     Fig.  2.  Frac- 
ture of  the  external  tuberosity  ofthe  femur 418 

XXIV. — Fracture  of  patella.     Ossification  of  ligamentum  patellae     ...        .    424 

XXV.— Fracture  of  upper  end  of  tibia 440 

XXVI. — Fracture  by  eversion  with  interposition  of  astragalus 456 

XXVII. — Longitudinal  fracture  of  lower  end  of  tibia  by  a  fall  upon  and  in- 
version of  the  foot " 466 

XXVIII. — Fracture  of  the  inner  portion  of  the  body  of  the  astragalus    ....     470 
XXIX. — r;ongenital  dislocation  of  hip 548 

xix 


XX  LIST  OF  PLATES. 

PLATE  PAGE 

XXX. — Congenital  dislocation  of  the  shoulder 686 

XXXI. — Figs.  1  and  2.   Midcarpal  fracture  dislocation .  778 

XXXII. — Midcarpal  fracture  dislocation 778 

XXXIII. — Midcarpal  fracture  dislocation,  profile  view -  778 

XXXIV.— Midcarpal  fracture  dislocation 778 

XXXV. — Midcarpal  fracture  dislocation,  after  removal  of  proximal  fragment 

of  scaphoid 778 

XXXVI. — Midcarpal  fracture  dislocation 778 

XXXVII. — Fig.  1.  Old  dislocation  backward  of  os  magnum,  side  view.     Fig.  2. 

Old  dislocation  backward  of  os  magnum,  antero-posterior  786 

XXXVIII. — Incomplete  outward  dislocation  of  the  knee 875 

XXXIX.— Subasti-agaloid  dislocation 912 


FRACTURES. 


(17) 


A  TREATISE 


FRACTURES  AND  DISLOCATIONS. 


CHAPTER  I. 

INTRODUCTION. 


By  Fracture,  in  the  surgical  sense  of  the  term,  is  meant  the  breaking 
of  a  bone  or  cartilage. 

The  liability  to  fracture  of  the  different  bones  of  the  body  varies 
greatly,  in  consequence  of  their  differences  in  size,  shape,  and  degree  of 
exposure  to  external  violence  or  extreme  muscular  action.  Hospital 
records  covering  periods  varying  in  length  from  five  to  eighty-seven 
years  have  been  tabulated  by  different  writers,  witii  the  object  of  deter- 
mining the  relative  degree  of  this  liability ;  but  it  is  evident  that  such 
statistics  cannot  contain  all  the  needed  facts,  for  the  reason  that  patients 
with  fractures  which  do  not  necessitate  confinement  to  the  bed  do  not  so 
generally  seek  hospital  care  as  those  with  fractures  which  do.  Com- 
bined hospital  and  dispensary  statistics  are  more  nearly  correct,  but 
even  they  differ  considerably  from  one  another  in  their  percentages, 
possibly  because  of  differences  in  the  occupations  and  mode  of  life  of 
the  communities  which  furnished  them.  I  have  compiled  the  follow- 
ing table  from  the  records  of  the  House  of  Relief  ("  Hudson  Street 
Hospital "),  of  which  I  am  the  attending  surgeon,  including  both  the 
In-  and  the  Out-patient  services.  The  hospital  is  the  only  one  in  Kew 
York  City  below  Canal  Street,  a  region  largely  given  over  to  trade, 
transportation,  and  manufacturing,  with  frequent  construction  of  large 
buildings,  and  in  which  there  is  only  a  laboring  resident  population. 


Hudson    Street    Hospital,   New  York:    Statistics    of    Fractures    Treated 
IN  Hospital  and  Dispensary,  1894-1905. 

Cases.  Cases.  Per  cent 

Cranium 772  Head 772  5.50 

Malar  bone  ......  29  "] 

Nasal  bones 672 

Superi(,rniaxilla  .    ...  46   i  Face  and  Neck   .    .    .   1281  8.79 

Inferior  maxilla  ....  502   | 

Zygoma 29    | 

Hyoid 3  J 


(19) 


20 


FRACTURES. 


Cases. 


Cases. 


Trunk 


1832 


Upper  extremity    .    .  6818 


Spine 66  "] 

Pelvis 75   I 

Coccyx 3   i 

Sternum 13   | 

Kibs 1675  J 

"  Upper  extremity  "    .    .    132  ] 
Clavicle     ..."...    662 

Scapula 66 

Humerus,  shaft  and  neck  411 

lower  end      209 

internal  epicondyle  .  6 
Radius  and  ulna  .  .  .  283 
Radius,  shaft 363 

CoUes's 1212 

Ulna,  shaft 318 

olecranon      118 

Carpus 15 

Metacarpus 1063 

Phalanges 1990 

Femur 540  ~ 

Patella 183 

Tibia,  or  tibia  and  fibula  943 
Abduction  and  adduction 

fractui'es  at  ankle    .  1089 

Fibula 233   i^  Lower  extremity    .    .  3863 

External  malleolus    .    .      33 
Internal  malleolus  ...       31 

Tarsus 151 

Metatarsus 326 

Toes 334 


Per  cent 


12.57 


46.80 


26.54 


Total 


14,566 


During  the  same  period  1527  dislocations  were  treated. 

Sex,  Fractures  are  more  numerous  in  men  than  in  women,  in  the 
proportion  of  about  three  to  one,  because  of  the  greater  exposure  of 
men  to  the  accidents  which  cause  them.  Mainly,  for  the  same  reason, 
the  proportion  varies  greatly  at  different  ages  ;  in  infancy  the  difference 
is  slight ;  in  middle  life  fractures  are  ten  times  as  frequent  in  men  as  in 
women  ;  between  the  ages  of  fifty  and  seventy  years  the  difference  again 
becomes  slight,  and  after  the  age  of  seventy  years  fractures  are  more 
common  in  women  than  in  men,  a  reversal  of  conditions  due  to  a  dispro- 
portionate increase  in  the  number  of  fractures  of  the  neck  of  the  fenuir. 

Age.  Gurlt^  tabulated  1383  cases  (hospital  and  dispensary)  with  ref- 
erence to  the  ages  of  the  patients,  and  found  in  the  first  decade,  265 ; 
in  the  second,  193  ;  in  the  third,  274 ;  in  the  fourth,  224;  in  the  fifth, 
154;  in  the  sixth,  155  ;  in  the  seventh,  72  ;  in  the  eighth,  38,  and  in 
the  ninth,  8.  Combining  these  with  statistics  showing  the  relative 
number  of  people  living  at  the  different  ages,  he  found  the  highest 
proportion  of  fractures  in  the  period  above  the  age  of  sixty  years. 
Malgaigne^  made  a  similar  tabulation,  using  only  hospital  cases,  and 
grouping  in  periods  of  five  years  he  found  that  the  periods  between 
fifty-five  and  eighty  were  practically  equal  to  one  another,  and  gave  the 
highest  proportion  according  to  ])opnlation. 


'  Gurlt :  Handbuch  der  Lebre  von  den  Knochonbriichen,  1862. 
^  Malgaigne:  Traite  des  Fractures  et  des  Luxations,  1847. 


INTRODUCTION.  21 

Season  affects  the  frequency  of  fracture  only  by  increasing  or  dimin- 
ishing the  exposure  to  the  accidents  which  occasion  them.  Falls  due 
to  ice  and  snow  in  winter  are  more  than  offset  as  a  cause  by  the  more 
varied  and  active  occupations  of  the  milder  months,  and  fractures  are, 
therefoi-e,  less  fre(][uent  in  winter  than  in  summer.  This  is  shown  by 
the  following  tabulation  of  the  fractures  treated  in  the  Hudson  Street 
Hospital,  according  to  months  : 

Hudson  Street  Hospitai,:  Fractures  in  1896,  Wards  and  Dispensary. 

January,  77         March,      130         June,  82        September,     105 

February,  88         April,        ]03         July,  148         October,  107 

December,  119         May,  97         August,         150         November,     11(5 

284  330  380  328 


Omitting  hand 
and  toes. 


57  84  104  -  92 

227  246  276  236 


The  maximum  is  found  in  the  summer  months,  the  minimum  in  the 
winter.  It  is  only  in  fractures  of  the  leg  that  the  winter  season  heads 
the  list,  and  yet  even  in  these,  as  the  following  table  shows,  a  decided 
monthly  maximum  is  found  in  March,  a  month  in  which  there  is  but 
little  snow  and  ice  in  New  York  : 

Fractures  op  the  Leg,  of  either  Bone,  and  Pott's  Fracture. 


January, 

19 

March, 

29 

June, 

9 

September, 

8 

February, 

20 

April, 

9 

July, 

11 

October, 

6 

December, 

21 

May, 

12 

August, 

25 

November, 

20 

60  50  45  34 

Fractures  of  the  femur  (shaft  and  neck)  give  the  following  totals  : 
Winter  16,  spring  17,  summer  8,  autumn  12;  those  of  the  upper  ex- 
tremity (clavicle,  humerus,  and  either  or  both  bones  of  the  forearm) 
give:  Winter  67,  spring  63,  summer  107,  autumn  72. 

Note. — For  other  statistics  see  Malgaigne,  Gurlt,  and  the  first  edi- 
tion of  this  work  ;  also  Wallace,  American  Journal  of  the  Medical 
Sciences,  1839  ;  Norris,  Ibid.,  1841  ;  Lente,  New  York  Medical  Journal, 
1851;  Lonsdale,  Fractures,  1838,  and  Scannell,  Boston  Medical  and 
Swgiced  Journal,  Nov.  15,  1906. 


CHAPTER  II. 

PATHOLOGY. 

The  Bone — Varieties :    Incomplete,  Complete,  Multiple,  Compound,  Gunshot. 
Displacements.     The  soft  parts. 

(A)  THE  BONE— VARIETIES  OF  FRACTURE. 

The  varieties  of  fracture  are  numerous  and  are  constituted  by 
differences  in  the  extent  of  the  injury  to  the  bone  or  to  the  surrounding 
soft  partSj  in  the  seat,  shape,  and  direction  of  the  fracture,  in  the  rela- 
tion of  the  fragments  to  each  other,  and  in  the  number  of  bones 
involved.  These  varieties  may  be  grouped  in  five  divisions,  marked 
by  important  clinical  differences  and  containing  many  subdivisions,  as 
follows : 

1.  Incomplete  fractures. 
(a)  Fissures. 

(6)  True  incomplete,  "  green  stick  ;"  bent  bone. 

(c)  Depressions. 

(c/)  Separation  of  a  splinter  or  of  an  apophysis. 

2.  Complete  fractures,  subdivided,  according  to 

(a)  Direction  and  character  of  the  line  of  fracture,  into  transverse, 
oblique,  longitudinal,  spiral,  toothed  or  dentate,  V-,  Y-,  or  T-shaped, 
and  comminuted ; 

(6)  Seat  of  the  fracture,  into  fracture  of  the  shaft,  of  the  neck,  of  the 
upper,  middle,  or  lower  third,  intercondyloid,  separation  of  epiphysis; 
and 

(c)  If  extending  into  a  joint,  intra-articular. 

3.  Multiple  fractures,  comprising  fractures  of  two  or  more  non- 
adjacent  bones  and  two  or  more  fractures  of  the  same  bone. 

4.  Compound  (or  open)  fractures. 

5.  Gunshot  fractures. 

The  term  sprain-frachire  has  been  lately  introduced  to  designate 
those  sprains  in  which  the  ligament,  instead  of  rupturing,  has  torn  off 
a  small  fragment  of  bone  at  its  attachment.  And  by  some  its  use  has 
been  extended  to  include  some  cases  in  which  a  much  larger  fragment 
has  been  broken  off  by  the  same  mechanism. 

The  term  simple  (or  closed)  fracture  is  commonly  used,  in  contradis- 
tinction to  the  term  compound,  to  indicate  that  there  is  no  associated 
wound  of  the  soft  parts  which  establishes  communication  between  the 
fracture  and  the  exterior.  Some  writers  make  also  a  class  of  compli- 
cated fractures  to  include  cases  in  which  some  important  injury  coexists; 
and  there  are  still  other  terms  in  use  to  indicate  peculiarities  which  do 
not  lend  themselves  easily  to  the  above  classification.  Such  are:  Spon- 
taneous fracture,  one  produced  by  the  minimum  of  violence;  pathological 
fracture,  one  favored  by  weakening  or  partial  destruction  of  the  bone  by 
disease;  direct  fracture,  one  occurring  at  the  point  where  the  causative 
(22) 


PATHOLOGY. 


23 


external  violence  is  received  ;  indirect  fracture,  one  occurring  at  a  dis- 
tance from  that  point ;  recent  and  old,  or  ununited,  fracture.  Another 
grouping  is  according  to  the  mechanism  of  production  :  fractures  by 
bending,  by  torsion,  by  crushing,  by  avulsion,  by  gunshot ;  with  sub- 
sidiary terms  :  fractures  hy  flexion  or  extension,  by  abduction  or  adduc- 
tion, by  eversion  or  inversion. 


Fig. 


bone   is 
ing    of 


1.  Incomplete  Fractures. 

Under  this  head  will  be  considered  fractures  in  which  the  continuity 
of  the  bone  has  not  been  completely  lost  or  a  fragment  has  not  been 
completely  detached. 

(rt)  Fissures.  This  variety  is  characterized  by  the  existence  of  a 
split  or  crack  in  the  bone,  one  which  does  not  entirely  circumscribe  a 
fragment  and  separate  it  from  the  rest  of  the  bone.  It  is  of  common 
occurrence  in  the  bones  of  the  cranium,  and  verv  rare  in  the  long;  bones 
except  when  associated  with  other  varieties.  It  is  almost  unknown  in 
the  short  or  spongy  bones. 

The  examples  of  isolated  fissure  of  long  bones  are  very  rare.  Fig. 
1,  copied  by  Gurlt  from  Froriep,  represents  one  extending  from  the 
greater  tuberosity  of  the  humerus  to  the  lower  fourth  of  the  shaft,  pro- 
duced in  a  boy  by  a  fall  upon  the  elbow.  Fissures  connected  with 
complete  fracture  are  common  ;  are  sometimes  very  long,  and  may 
extend  into  a  neighboring  joint.  A  very  long  fissure  is  sometimes 
termed  a  longitudinal  fracture. 

The  mechanism  by  which  a  long 
isolated  fissure  is  produced  in  a  long 
probably  the  forcible  bend- 
the  bone.  This  is  plainly 
indicated  in  a  case  reported  by  De- 
brou  in  1843,  and  quoted  by  Gurlt  as 
a  case  of  infraction.  The  patient,  a 
man  sixty-two  years  old,  fell  while 
walking,  and  injured  his  thigh.  Ery- 
sipelas set  in  and  caused  his  death. 
At  the  autopsy  a  fissure  was  found 
imder  the  untorn  periosteum,  extend- 
ing six  inches  downward  from  the  tro- 
chanter minor,  and  this  fissure  could 
be  made  to  widen  by  pressure  upon 
the  ends  of  the  bone. 

The  diagnosis  cannot  be  made  with 
certainty,  except  when  the  bone  is  ex- 
posed to  direct  examination  ;  but  it 
can  be  inferred  with  much  proba- 
bility in  some  forms  of  fracture  with 
which  it  is  usually  associated,  such  as 
V-shaped  fractures  of  the  tibia.  Giese,^ 
reporting  a  case  involving  the  tibia,  calls 
attention  to  the  discrepancy  between  the  slight  objective  signs  and  the 
extreme  sensitiveness  and  interference  with  function. 

'Giese:  Miincheuer  med.  Wochenschrift,  lyoci,  No.  9. 


Fissure      of 
the   humerus. 

(Gurlt.) 


Partial  fmoturo  of  the 
fibuhi.  n,  tlie  head ;  b, 
tlie  malleolus. 


24  FRACTURES. 

Except  when  it  extends  into  a  joint  the  importance  of  a  fissure  is 
probably  sli,2:ht,  and  is  dominated  by  that  of  the  associated  lesions.  In 
some  cases  the  injury  has  been  promptly  or  tardily  followed  by  suppura- 
tion beneath  the  periosteum  or  within  the  bone. 

(6)  True  Incomplete,  "  Green-stick  Fracture  "  ;  Infraction  ;  Bent  Bone, 
or  Curvature  Without  Fracture.  This  variety  is  characterized  by  a  frac- 
ture involving  only  a  portion  of  the  thickness  of  a  long  bone,  and 
combined  with  a  bending  of  the  bone  at  the  seat  of  fracture.  In  its 
consideration  is  included  also  that  of  the  rare  cases  of  curvature  with- 
out recognizable  fracture,  a  variety  which  has  only  an  academical 
interest,  for  it  cannot  be  recognized  clinically.  Its  possibility  has  been 
demonstrated  experimentally  upon  young  animals  and  by  a  single 
specimen  belonging  to  Prof.  Uhde,  the  ulna  of  an  adult  much  bent  by 
a  machinery  accident,  and  showing  no  trace  of  fracture. 

The  injury  appears  ordinarily  as  a  short  transverse  fracture,  continu- 
ous with  one  or  more  longitudinal  ones  of  variable  length  ;  sometimes 
there  is  no  transverse  line,  but  only  oblique  ones  running  from  the 
angle  upw^ard  or  downward.  The  appearance  can  be  closely  imitated 
by  over-bending  a  green  or  tough  stick,  a  fact  that  has  given  this  form 
of  fracture  a  name  by  which  it  is  very  commonly  known. 

This  fracture  is  seen  most  frequently  in  the  bones  of  the  forearm, 
then  in  the  clavicle,  and  very  rarely  in  the  bones  of  the  arm,  leg,  and 
thigh.  The  great  majority  of  cases  occur  in  those  under  the  age  of 
fifteen  vears.  In  the  forearm  it  may  be  found  in  only  one  bone,  the 
other  being  completely  broken.  The  usual  cause  is  a  fall,  but  I  have 
seen  several  cases  in  which  the  cause  was  the  forcible  bending  of  the 
forearm  over  a  rigid  body,  as  when  the  limb  is  caught  between  a  shaft 
and  its  belting. 

The  chief  symptoms  are  deformity,  consisting  in  an  angular  devia- 
tion of  a  portion  of  the  limb  or  bone,  and  localized  pain  on  pressure  at 
the  angle.  The  deviation  can  be  more  or  less  completely  corrected  by 
the  use  of  force,  and  the  correction  may  be  accompanied  by  crepitus  and 
followed  by  abnormal  mobility,  the  fracture  having  been  made  complete. 

The  prognosis  is  favorable  as  regards  correction  of  the  deformity  and 
repair.  Ordinarily,  the  limb  can  be  straightened  by  the  surgeon's 
hands  alone,  aided,  perhaps,  by  the  pressure  of  his  knee  against  the 
angle ;  and  the  surgeon  should  not  be  deterred,  by  the  fear  of  making 
the  fracture  complete,  from  using  all  the  force  that  is  necessary. 

(c)  Depressions.  I  limit  the  use  of  this  term  to  those  cases  in  which 
a  portion  of  the  outer  layer  of  a  flat  bone  or  the  spongy  portion  of  a 
long  bone  is  driven  inward  by  direct  violence,  usually  a  blow  wath  a 
pointed  instrument.  The  injury  is  most  frequently  seen  in  the  vault 
of  the  skull,  and  is  there  generally  termed  a  fracture  of  the  outer  table. 
It  is  occasionally  seen  in  the  limbs  in  connection  with  complete  fracture. 

{(T)  Separation  of  a  Splinter  or  of  an  Apophysis.  In  this  variety  are 
included  two  classes  of  fractures  which  differ  widely  in  their  mode  of 
production,  but  have  this  in  common  :  that  the  fragment  does  not  com- 
prise the  entire  breadth  or  thickness  of  the  bone,  and  that  consequently 
the  continuity  of  the  latter  is  not  destroyed.      In  the  first  class  a 


PATHOLOGY. 


25 


•splinter  or  fragment  of  bone  is  broken  off  by  direct  violence,  ns  by  a 
cutting'  instrument ;  in  the  second  class  a  bony  ]>rominence  is  torn  off 
bv  the  violent  contraction  of  the  muscle  attached  to  it  or  by  traction 
through  a  ligament. 

The  separation  of  a  splinter  or  scale  of  bone  by  a  sword-cut  or  bullet 
is  not  uncommon  in  the  spongy  bones  or  the  spongy  extremities  of  long 
bones,  and  has  also  been  known  to  occur  in  the  shaft  of  the  tibia.  It 
is  an  injury  which  should  be  classed  rather  among  wounds  of  bones 
than  among  fractures.  The  separation  of  a  splinter  by  direct  violence, 
unaccompanied  by  a  wound  of  the  soft  parts,  occurs  in  the  bones  of  the 
face,  at  the  crest  of  the  ilium,  and  at  exposed  points  upon  the  extremi- 
ties of  the  long  bones. 

Avulsion  of  an  apophysis,  or  of  a  scale  of  bone,  by  muscular  action 
is  a  far  more  common  accident  than  the  one  just  described.  The  lesion 
consists  in  the  fracture  of  an  apophysis  at  its  base  or  in  the  tearing 
oif  of  a  portion  of  bone  to  which  a  muscle  or  tendon  is  attached. 


2.  Complete  Fractures. 

The  term  complete,  when  applied  to  a  fracture  of  a  long  bone,  indi- 
cates that  the  bone  is  divided  by  a  line  of  fracture  crossing  from  side 
to  side  or  obliquely  across  the  end. 


Fig.  3. 


Fig.  4. 


Fig.  5. 


A 


\ 


Humerus. 


Femur. 
(Traeiugs  from  skiagrams. ] 


(a)  Subdivision  According  to  the  Direction  of  the  Line  of  Fracture. 
Such   terms  in  use   are   tran.wersr,  ohCKjue,  splintered,  apiral,  y-.s/iaped, 


26 


FRACTVEES. 


T-  or  Y-shajjed,  dentate,  longitudinal,  and  comminuted.  Apparently  as 
a  result  of  physical  conditions,  fractures  by  direct  or  indirect  violence 
which  bends  a  long  bone  are  either  practically  transverse  or  markedly 
obliq^ue,  with  or  without  splintering. 

The  line  of  a  transverse  fracture  does  not  deviate  more  than  about 
15  or  20  degrees  from  that  of  the  transverse  axis ;  that  of  an  oblique 
fracture  lies  near  an  angle  of  50  degrees.  A  transverse  fracture  may 
be,  but  rarely  is,  exactly  transverse  and  smooth  (Fig.  6) ;  clinically 
such  details  cannot  be  recognized  unless  the  fracture  is  compound,  and 
the  diagnosis  of  the  variety  is  made  on  the  fact  that  the  end  of  the 
fragment  can  be  felt  through  the  overlying  soft  parts  to  be  approximately 
square  and  smooth.  In  the  oblique  variety  the  line  of  fracture  may  be 
single  (Fig.  9)  or  multiple  (Fig.  8),  circumscribing  in  the  latter  case 


Fig.  6. 


Fig. 


Transverse  fracture  of  the 
femur.     ^Gvp.lt.) 


Fracture  of  humerus. 
(V.  Bruns.) 


one  or  more  detached  fragments  which  apparently  are  formed  on  the 
side  of  the  concavity  created  by  the  bending  of  the  bone  {sp/i)itered). 
This  is  characteristic  of  the  fractures  produced  by  bending.  The  line 
of  fracture  in  either  form  may  be  markedly  irregular  on  either  or  both 
fragments.  AVhen  this  irregularity  is  found  on  Ixnli  fragments  the 
term  toothed  or  dentate  is  applied  ;  when  it  is  f>un(]  onlv  on  one  side 
the  absence  of  a  corresponding  line  on  the  other  is  due  to  the  crushing 
of  the  bone  or  to  the  splitting  oif  of  one  or  more  large  frau-nients. 
Spiral  fractures,  which  are  rare,  are  proihiced  by  torsion  of  tlie  bone, 


PATHOLOGY. 


27 


and  are  found  in  the  femur,  humerus,  and  tibia.    In  the  latter  they 
are  also  known  as  ^-shaped  (Fig.  10),  and  can  be  readily  recognized 


Fig.  8. 


Fig.  9. 


Oblique  fracture  by  direct  pressure. 

(KOCHER.) 


Spiral  fracture  by  outward  rotation  of 
lower  end.    (Kochek.) 


by  the  sharp  point  of  the  upper  fragment,  which  can  be  felt  midway 
between  the  crest  and  the  internal  border  of  the  bone.  From  the 
re-entrant  angle  corresponding  to  this  point  a  fissure  runs  down  to  the 
ankle-joint. 

Under  the  term  longitudinal  are  included  very  oblique  fractures  rnn- 
ning  from  one  side  of  the  bone  to  the  other,  fractures  rnnning  from 
one  end  of  the  bone  to  or  nearly  to  the  other,  and  fractures  which  split 
lengthwise  a  longf  fragment  intermediate  between  two  transverse  frac- 
tures.  The  last-named  form  is  prodnced  only  by  great  crushing 
violence,  and  the  prognosis  is  very  bad.  In  the  other  forms  the 
violence  is  indirect,  apparently  a  bend  or  twist  of  the  bone  or  a  blow 
received  at  one  end;  the  ill  results  which  have  so  commonly  followed 
appear  to  be  due  in  some  to  the  implication  of  one  or  both  joints  or  to 
a  failure  to  recognize  the  injury  and  maintain  immobility.  The  most 
marked  cases  are  one  reported  by  Kronlein,^  a  fracture  of  the  humerus 
^  Kronlein  :  Deutsche  Zeitsch.  f.  C'iiir.,  1«73,  p.  132. 


28 


FRACTURES. 


Fig.  10. 


from  the  shoulder  to  the  elbow-joint,  in  a  man  twenty-seven  years  old, 
by  an  attempt  to  raise  a  heavy  ladder,  and  one  by  Cloquet,  in  1831,  a 
fracture  of  the  femur  from  the  intercondyloid  notch  to 
a  point  just  below  the  trochanter  minor,  by  a  fall  from 
a  roof. 

A  comminuted  fracture  of  the  shaft  of  a  long  bone  is 
one  in  which,  in  addition  to  the  complete  division  of  the 
bone  into  two  fragments,  there  is  also  extensive  splinter- 
ing of  the  portion  of  bone  adjoining  the  fracture  or  of 
one  of  the  fragments  (Figs.  11  and  12).  In  a  comminuted 
fracture  of  a  flat  bone  the  bone  or  a  portion  thereof  is 
broken  into  several  rather  large  fragments,  with  or 
without  additional  small  ones ;  in  this  use  of  the  term 
fractures  showing  only  two  or  three  fragments,  and 
those  rather  small,  aSfe  excluded,  the  line  of  distinction 
being  of  necessity  vague  and  arbitrary.  In  the  short 
bones  and  the  spongy  ends  of  the  long  bones  comminu- 
tion is  frequently  associated  with  crushing  of  the  spongy 
tissue,  or  the  end  of  the  diaphyseal  fragment  may  be 
driven  into  the  expanded,  spongy  end,  crushing  it  or 
splitting  it ;  to  this  form  the  term  compression  fracture 
is  sometimes  given,  specially  at  the  upper  end  of  the 
humerus  and  tibia  and  in  the  bodies  of  the  vertebrse. 
If  the  two  main  fragments  are  rather  firmly  held  to- 
gether in  their  new  relations  the  condition  is  termed 
impactiofi  or  impacted  fracture  (Fig.  13).  If  the  crush-  v-shaped  fracture. 
ing  of  the  spongy  tissue  has  taken  place  without  much 
splintering  of  the  cortical  layer  the  term  fracture  with  crushing  is  used 
(Fig.  14).  This  crushing  of  spongy  tissue  is  effected  by  breaking 
Fig.  11.  Fig.  12. 


Comminuted  fracture  of  the  femur, 
with  splitting  of  the  condyles. 


Comminuted  fracture  of  the  lower 
end  of  the  radius.  Palmar  aspect. 


PATHOLOGY, 


29 


down  the  inuuinerable  fine  lamellse  of  bone  and  forcing  out  the  fat 
within  the  meshes,  as  a  handful  of  snow  or  a  wet  sponge  is  compressed, 
and  the  result  is  equivalent  to  an  actual  loss  of  tissue ;  that  is,  if  the 
main  fragments  are  replaced  in  their  original  positions  a  gap  is  left 
between  them  corresponding  to  the  position  and  extent  of  the  crushing. 
This  gap  is  often  too  large  to  be  filled  by  new  bone,  formed  during 
repair ;  consequently,  a  full  correction  of  the  displacement  is  inadvis- 
able, even  when  possible,  lest  failure  of  union  should  result,  and  the 
surgeon  must  be  content  to  obtain  union  with  some  deformity. 


Fig.  13. 


Fig.  14. 


Intra-articular  fracture  of  the  head 
of  the  tibia,  with  impaction  and  sepa- 
ration of  the  upper  fragments. 


Fracture  of  the  calcaneum,  with  crushing. 


(6)  Varieties  Dependent  Upon  the  Seat  of  the  Fracture. — A  fracture 
may  occupy  any  portion  of  the  bone  and  be  known  by  its  name  ;  for 
example,  fracture  of  the  neck  of  the  femur,  of  the  lower  third  of  the 
tibia,  of  the  head,  of  the  shaft,  of  the  inner  condyle,  of  the  acromion  ; 
intercondyloid  fracture,  when  it  passes  across  the  shaft  and  also  down- 
ward between  the  condyles ;  separation  of  the  epiphysis. 

Separation  of  the  Epiphysis}  This  term  is  limited  to  separation  of 
epiphyses  which  have  not  yet  become  united  by  bone  with  the  shaft. 
This  union  takes  place  in  the  diiferent  bones  at  diflPerent  ages,  but  is 
usually  complete  in  all  in  the  female  at  the  age  of  twenty-two  years, 
and  in  the  male  at  twenty-five  years.  Bruns^  collected  81  cases,  with 
101  separations,  in  which  direct  examination  of  the  seat  of  injury  was 
possible;  the  points  of  greatest  frequency  were  the  lower  end  of  the 
femur  28,  lower  end  of  the  radius  25,  and  upper  end  of  the  humerus 
11.  Of  the  52  cases  in  which  the  age  was  given,  44  were  between 
ten  and  nineteen  years  old,  8  between  one  and  nine  years.  Of  61  in 
which  the  line  was  exactly  described,  the  line  in  23  ran  exactly  along 
the  face  of  the  conjugal  cartilage,  in  5  it  ran  through  the  cartilage, 
and  in  33  partly  along  the  cartilage  and  partly  through  the  adjoining 

'  The  first  work  upon  this  subject  is  by  G.  C.  Reichcl,  "  D(!  Epiphysiuni  ab  Ossiurn 
Diaphysi  Diductioue,"  j)ublishcd  at  Leipsic  in  1794.  Maiuiuat's  thesis,  in  1S77,  and 
l?riins'  article,  in  1878,  wen;  tlie  first  in  wliich  any  consid('ral)lc  number  of  cases  was 
cdlU'ctcd.  Later  artich's  will  be  referred  to  in  connection  with  (he  diflerent  epiphyses, 
t^uite  recently,  1898,  a  hir^e  work  nixin  the  sn1)ject.  has  been  published  by  John  Poland, 

''■  Bruus:  Arch.  f.  klin.  Chir.,  1878,  vol.  .\xii.  p.  34:{. 


30 


FRACTURES. 


"chondroid"  tissue  on  its  diaphyseal  side.  An  important  feature  is 
the  fact  that  the  periosteum  of  the  adjoining  portion  of  the  shaft  is 
freely  stripped  off,  preserving  its  continuity  to  a  large  extent  with  the 
epiphysis. 

The  mode  of  production  appears  usually  to  be  by  cross-strain,  the 
limb  being  bent  beyond  the  limit  of  normal  motion  in  the  correspond- 
ing joint  or  in  a  direction  in  which  there  is  normally  no  motion ;  for 
example,  lateral  bending  at  the  knee. 

The  displacement  may  be  very  slight  or  so  great  as  wholly  to  sepa- 
rate the  fractured  surfaces  from  each  other.  Colles's  fracture  at  the 
lower  end  of  the  radius  in  the  young  is  occasionally  a  separation  of 
the  epiphysis  with  slight  displacement  (see  Plate  XIX.,  Fig.  2) ;  at 
the  upper  end  of  the    humerus  the  displacement  is  usually  equal  to 

Fig.  15. 


Separation  of  the  epiphysis.    Periosteum  partly  intact.    (Thudicum.) 

about  half  the  thickness  of  the  bone  ;  at  the  elbow  it  may  be  complete 
backward    or  inward,  but  is  usually  incomplete  inward. 

The  diagnosis  is  made  in  the  cases  of  slight  displacement  on  the 
history  of  the  injury  and  tenderness  on  pressure  limited  to  the  line  of 
junction  of  the  epiphysis  and  shaft;  in  the  others  by  recognition  of  the 
deformity  and  of  the  size  and  shape  of  the  fragment.  When  the  dis- 
placement is  great  reduction  may  be  seriously  opposed  by  the  interpo- 
sition of  the  loosened  periosteum. 

The  prognosis  is  affected  by  the  possibility  of  arrest  of  growth  due 
to  an  uncorrected  displacement  or  to  premature  ossification  of  the  con- 
jugal cartilage.  A  few  such  cases  have  been  reported.  This  defi- 
ciency of  growth  is,  of  course,  most  marked  in  those  who  receive  their 
injury  at  an  early  age,  and  secondly  in  those  cases  in  which  the 
affected  epiphysis  normally  takes  the  larger  part  in  the  growth  of  the 
bone  in  length,  namely,  the  upper  end  of  the  humerus  and  tibia  and 
the  lower  end  of  the  femur  and  radius.  I  have  seen  two  cases  in 
which  this  injury  at  the  lower  end  of  the  radius  at  the  age  of  fourteen 


PATHOLOGY.  31 

years  produced  a  late  deformity  exactly  resembling  that  of  a  bad  Colles's 
fracture.     (See  Plate  XIX,  Fig.  1.) 

(c)  Intra-articular  or  articular  fractures  are  those  in  which  the  main 
line  of  fracture  or  a  subsidiary  one,  extends  into  a  joint.  The  forms 
vary  from  a  simple  fissure  extending  into  the  joint  from  a  distant  frac- 
ture with  little  or  no  injury  to  the  capsule  to  a  fracture  in  which  the 
articular  end  of  a  bone  is  broken  into  several  widely  displaced  pieces 
with  much  laceration  of  the  capsule  and  periarticular  tissue.  They 
include  also  that  form  in  which  the  fracture  lies  wholly  within  the  joint, 
with  little  or  no  injury  to  the  joint,  as  in  fracture  of  the  narrow  part 
of  the  neck  of  the  femur,  close  to  the  head,  and  in  fracture  of  the  capi- 
tellum  of  the  humerus,  and  some  fractures  of  the  carpal  scaphoid ;  to 
this  form  the  term  intra-articular  is  often  limited.  Common  examples 
are  fractures  of  either  condyle  of  the  femur  or  humerus,  intracondyloid 
fractures  of  the  same  bones,  fractures  of  the  patella  and  olecranon. 
The  special  importance  of  the  variety  arises  partly  from  the  implication 
of  the  joint  in  the  inflammatory  reaction  following  the  trauma,  but 
mainly  from  the  change  in  the  mechanical  conditions  produced  by  the 
ilisplacement  of  the  fragment,  the  callus,  and  the  implication  of  the 
capsule  and  periarticular  tissues.  There  is  but  little  recognizable 
regularity  in  the  eifects  produced  by  these  different  factors,  lesions 
apparently  slight  sometimes  causing  complete  anchylosis,  and  extensive 
disjilacement  of  a  fragment  sometimes  causing  only  slight  interference 
with  function.  The  most  marked  limitations  of  motion  appear  usually 
to  be  the  consequence  of  injury  to  the  capsule  and  adjoining  soft  parts 
by  which  they  are  shortened  or  so  bound  togetiier  as  to  restrict  the 
movements.  This  factor  needs  specially  to  be  borne  in  mind  in  decid- 
ing upon  the  propriety  of  operation  in  these  cases  and  upon  the  method 
of  operation.  AVhen  a  fragment  including  a  portion  of  bone  well  out- 
side the  capsule  has  undergone  such  displacement,  usually  by  rotation, 
as  to  separate  its  articular  portion  wholly  or  in  great  part  from  the  cor- 
responding surface  of  the  associate  bone  an  operation  is  usually  required 
to  restore  it  to  its  place.  If  the  fragment  is  smaller  and  wholly  intra- 
articular, or  even  if  retaining  slight  capsular  connection,  it  is  usually 
better  to  remove  it,  for  it  is  unlikely  to  maintain  its  vitality.  In  the 
young  excessive  formation  of  bone  outside  of,  but  near  to,  the  joint  as 
the  result  of  the  traumatic  irritation  of  the  periosteum  may  also  me- 
chanically limit  the  motions  of  the  joint. 

3.  Multiple  Fractures. 

This  term  is  applied  to  the  simultaneous  fracture  of  two  or  more 
non-adjacent  bones  and  two  or  more  fractures  of  the  same  bone  whose 
lines  are  not  continuous  with  one  another.  The  term  double  is  also 
used  when  there  are  only  two  fractures.  This  definition  is  intended 
to  exclude  simultaneous  fracture  of  both  bones  of  the  leg  or  forearm 
and  fractures  which  involve  two  or  more  adjacent  bones  of  the  skull 
or  pelvis.  The  term  is  frequently  applied  to  fracture  of  two  or  more 
adjacent  ribs,  and  sometimes  to  cases  of  extensive  splintering  of  the 
flat  bones. 


32  FEACTUBFS. 

Multiple  fractures  of  a  single  bone  are  caused  bv  violence,  usiiallv 
great,  acting  in  part  directly  against  the  shaft,  as  tlie  tall  of  a  heavy 
weight  or,  as  in  two  of  my  own  cases,  by  the  striking  of  the  tiiigh 
against  a   tree  when  the  patient  was  thro"\ATi  from  a  carriage.     The 

condition  may  he  serious  as  tij  life.  l;)ecanse  of  the  shock  of  the  injurv, 
and  in  respect  of  restnratidn  of  form  and  function,  because  of  the  diffi- 
culty of  controlling  the  position  of  the  intermediate  fragment.  There 
is  also  the  chance  of  overlooking  one  ijf  the  fractures. 

Multiple  fractures  of  different  bones  are  also  usually  caused  liv 
great  violence  :  the  jH'ognnsis  is  affected  much  more  liy  the  associated 
injuries  and  shock  than  by  the  multiplicity  of  the  fractures.  If  the 
patient  survives  the  primary  effects  of  the  accident  the  fractures  heal 
in  the  ordinary  manner. 

4.  Compound  (or  Open)  Fractures. 

A  compound  fracture  is  one  in  which  communication  between  the 
fracture  and  the  external  air  is  established  through  a  wound  of  the 
soft  parts.  The  importance  of  this  communication  arises  through  the 
possibility  of  infection  of  the  wound  from  without,  with  all  the  risks 
involved  in  the  consecpient  suppuration  of  the  bone  and  the  lacerated 
soft  parts.  In  addition,  a  large  proportion  of  compound  fractures  are 
caused  by  direct  violence,  and  the  consequent  laceration  of  the  over- 
lying soft  parts  is  such  as  to  he  a  serious  addition  to  the  fact  of  fracture. 
In  other  cases  the  external  wound  may  l)e  merely  a  puncture  made  l)y 
the  broken  end  of  the  bone,  which,  under  suitable  treatment,  heals  in 
a  few  days,  making  the  fracture  thenceforth  a  simple  (closed)  one, 

A  fracture  that  is  simple  at  tirst  may  be  made  compound  by  the 
sloughing  of  the  overlying  skin  in  consequence  of  its  injury  by  the 
primary  violence  or  of  pre-sure  i;p(in  it  bv  a  displaced  fragment,  or 
bv  the  later  forcing  of  the  sharp  end  of  a  fragment  through  the  skin 
in  tlie  agitation  of  delirium  or  in  an  attempt  to  tise  the  limb  while  in 
iijnorance  of  the  character  of  the  iniurv  that  has  been  received. 

In  determining  the  compound  character  ot  a  Iracture  it  is  sutbcient 
to  establish  the  fact  that  the  wound  of  the  soft  parts  extends  through 
the  enveloping  fascia  and  to  the  immediate  neighborhood  of  the  seat 
of  fracture,  for  even  if  the  gross  le--ion  sliould  not  extend  to  the 
broken  surface  of  the  bone,  yet  the  minuter  lacerations  and  the 
extravasated  blood  create  a  path  fir  the  spread  of  infectiou  that  brings 
the  condition  fully  within  the  detinition  and  the  special  dangers. 

The  proo:nosis  varies  so  greatly  wirli  the  extent  and  character  of  tlie 
iniurv  to  the  snft  parts  that  statistics  which  take  no  account  of  these 
variations  have  but  little  value.  A  fracture  inviduce^l  by  indirect 
violence  and  made  compound  by  a  puncture  of  the  skin  by  the  end  of 
a  subcutaneous  bone,  su^h  a-  tlie  ulna  or  tilna.  nun'  be  cuntidently 
expected  to  heal  under  apprnpiiate  tri'atrneut  a~  kindly  and  promptly 
as  a  simple  fracture;  while  nue  ]in>dnred  hy  direct  violence  and 
accompanied  by  destruction  of  the  -kin  and  mu-cles  can  heal  only  by 
granulation,  and  will  prubably  .-u])]-iinYitr  n"twith-tandiug  all  thr  care 
that  mav  be  given  it;   or,  the  a:-:-"eiatt'd  damage  to  the  -ntt  part.-  mav 


PATHOLOGY.  33 

be  such  that  the  limb  would  be  useless  even  if  the  wound  should  heal. 
The  most  virulent  and  rapidly  progressive  infections  appear  with  ex- 
ceptional frequency  in  compound  fractures  accompanied  by  much  bruis- 
ing or  laceration  of  the  muscles  ;  their  production  is  presumably  favored 
by  the  local  reduction  of  vitality. 

The  shock  of  the  injury  is  usually  much  greater  than  that  of  simple 
fracture,  and  may  cause  death  in  a  few  hours,  and  the  probability  of 
the  existence  of  serious  associated  lesions  is  also  greater  because  of  the 
usually  greater  violence  that  has  produced  the  fracture.  This  is  shown 
by  the  following  statistics:  During  two  years,  February,  1895,  to 
February,  1897,  there  were  received  at  the  Hudson  Street  Hospital 
70  compound  fractures  of  the  limbs,  exclusive  of  those  of  the  hand. 
Eleven  of  these  patients  died  within  twenty-four  hours  after  the  acci- 
dent, 3  of  the  11  having  also  a  fracture  of  the  base  of  the  skull  ;  4 
more  died  within  three  days  after  the  accident,  making  in  all  15 
deaths  (or  12,  if  the  fractures  of  the  skull  are  excluded)  directly  due 
to  the  shock  of  the  injury,  a  mortality  of  21  per  cent.  This  is  largely 
in  excess  of  that  following  simple  fractures,  although  they,  too,  may 
be  accompanied  by  other  grave  lesions  or  by  severe  shock,  or  may 
lead  to  a  fatal  pneumonia  or  attack  of  delirium  tremens.  I  cannot 
give  the  final  result  in  the  remaining  55  cases  of  my  list,  because 
many  of  them  were  transferred  to  their  homes  or  to  other  hospitals 
after  they  had  recovered  from  the  primary  effects  of  their  injuries. 
At  least  three  of  them  underwent  amputation. 

Mumford,'  collating  300  cases  (excluding  those  that  died  within  the 
first  twelve  hours  and  those  treated  by  primary  amputation)  received 
at  the  Massachusetts  General  Hospital  during  the  preceding  eight 
years,  found  a  mortality  of  30,  or  10  per  cent.,  the  causes  of  death 
being  sepsis,  10;  shock,  7;  dehrium  tremens,  6;  fat  embolism,  3; 
gangrene,  3;  nephritis,  1.  The  highest  mortality  was  in  fractures  of 
the  femur — 25  cases  with  7  deaths,  28  per  cent. 

The  principles  of  treatment  are  to  transform  the  fracture  into  a 
simple  one  as  promptly  as  possible,  to  minimize  suppuration  and  keep 
it  superficial  when  it  is  inevitable,  and  to  protect  against  other  infec- 
tion while  the  wound  is  open,  meanwhile  immobilizing  the  fragments 
by  suitable  splints.  Under  the  protection  of  strict  asepsis  (including  in 
that  rigid  disinfection  of  the  crushed  soft  parts  in  fractures  by  direct 
violence)  the  question  of  the  need  of  amputation  may  often  be  post- 
poned until  after  the  progress  of  the  case  shall  have  clearly  shown 
whether  or  not  the  limb  can  be  saved. 

5.  Gunshot  Fractures. 

The  call  for  separate  consideration  of  this  variety  of  compound  frac- 
tures comes  through  peculiarities  of  the  lesions  and  dangers  consequent 
upon  the  small  size  and  the  velocity  of  the  ]>rojectile.  The  subject, 
consequently,  is  rather  more  limited  than  its  title  might  suggest,  and 
does  not  include  fractures  by  large  balls  or  pieces  of  shell,  in  which 

I  Mumford :  Boston  Medical  and  Surgical  Journal,  May  10, 1894. 


34 


FRACTURES. 


the  extensive  laceration  of  the  soft  parts  is  even  more  important  than 
the  fracture. 

The  special  features  are  the  usually  extensive  splintering  and  As- 
suring of  the  bone  and  the  bruising  of  the  tissues  along  the  track  of 
the  bullet  which  may  prevent  prompt  healing  of  the  wound.  These 
features  are  found  in  varying  degrees,  corresponding  to  the  velocity  of 
the  ball  and  to  its  size.  A  ball  whose  force  is  nearly  spent  may,  on 
striking  the  shaft  of  a  long  bone,  do  no  injury  at  the  point  of  impact, 
but  may  yet  cause  a  curved  fissure  nearly  circumscribing  a  cortical  frag- 


FiG.  16. 


Fig.  1/ 


Contusion  of  side  of  femur  by  pistol-ball;  "symmetrical" 
fissure  of  the  opposite  side.    (Poulet  and  Bousquet.) 


Transverse  fracture  of  the  clavicle 
by  a  spent  ball.    (Ricaed.) 


ment  on  the  opposite  side  (Delorme,  Fig.  16)  ;  if  its  speed  is  slightly 
greater,  and  especially  if  it  strikes  the  spongy  end  of  the  bone,  it  causes 
a  depression  of  the  surface  only  ;  if  the  ball  is  large  and  its  velocity 
low,  and  the  point  struck  is  near  the  centre  of  the  shaft,  a  transverse 
fracture  or  an  oblique  one  may  be  produced.  At  higher  velocities  the 
bone  is  perforated,  with  more  or  less  splintering  and  Assuring,  or  the 
entire  cylinder  for  a  length  of  one  or  two  inches  is  split  into  small  frag- 
ments which  are  driven  far  into  the  surrounding  tissues.  With  the 
latter  may  be  associated  extensive  lacerations  of  the  soft  parts  on  the 
distal  side.  In  other  cases  the  bone  is  fissured  or  split  into  large  frag- 
ments on  each  side.  A  bullet  striking  close  to  the  side  of  the  .shaft 
may  cause  an  oblique  fracture. 

Figs.  18  to  24  represent  specimens  obtained  experimentally  by  Col. 
La  Garde,  of  the  Army  Medical  College,  AVashington,  using  modern 
weapons  of  .30  and  .38  calibre  and  giving  high  velocities.  The  coni- 
minution  caused  by  the  small  jacketed  bullets  of  modern  warfare  is 


PLATE  I 


Fracture  of  Radius  by  Snaall   Bullet  of  High  Velocity  entering 
at  the  Hand  and  emerging  at  the  EDdow. 


PATHOLOGY. 


35 


even  greater  than  that  shown  in  these  figures,  the  fragments  being 
smaller  and  more  numerous. 

Occasionally  the  bone  may  be  simply  perforated  or  notched,  and  then 
broken  by  the  subsequent  use  of  the  limb.  I  have  seen  two  such  cases : 
in  one  the  patient  was  shot  by  a  policeman,  and  as  he  ran  away  the 
femur  broke  at  the  point  where  it  had  been  perforated ;  he  died  of  tet- 
In  the  other,  fracture  of  the  leg,  the  same  sequence  was  ob- 


anus. 


served,  but  the  patient  survived,  and  the  exact  character  of  the  injury 
caused  by  the  bullet  remained  unknown. 

In  the"  case  shown  in  Plate  I.,  in  which  the  ball  entered  between  the 
fingers  and  emerged  above  the  elbow  after  extensively  splintering  the 
lower  half  of  the  radius,  the  skin  of  the  forearm  was  torn  longitudin- 
ally in  several  places,  apparently  by  the  distending  efiect  of  the  ball. 


Fig.  18. 


Fig.  19. 


Figs.  18  and  19.— Experimental  gunshot  fractures  with  .30  and.  38  calibre  bullets  at  high  velocity. 

(U.  S.  Army  Med.  Museum.) 

In  fractures  by  a  charge  of  small  shot  at  close  range  the  laceration 
af  the  soft  parts  is  the  predominant  feature.  In  those  of  the  cranium, 
chest,  and  pelvis  the  associated  visceral  injuries  are  the  most  important ; 
thus,  one  of  my  patients  died  from  the  injury  done  to  his  brain  by  a 
single  bird  shot,  size  No.  7,  which  entered  through  a  very  thin  part  of 


36 


FRACTURES. 


Fig.  20. 


Fig.  21. 


Figs.  20-23.— Experimental  gunshot  fractures  with  .30  and  .38  calibre  bullets  at  high  velocity. 

(U.  S.  Army  Med.  Museum.) 


PATHOLOGY.  37 

the  frontal  bone  just  below  the  niner  end  of  the  eyebrow.  The  removal 
of  the  bullet,  even  from  the  brain,  is  not  essential  to  recovery,  and  a 
search  for  it  may  easily  be  harmful. 

The  present  (1916)  war  has  been  marked  by  a  great  increase  in  the 
mortality  and  amputations  consequent  upon  this  injury,  because  of  the 
great  frequency  and  severity  of  infection,  especially  "that  of  the  gas 
bacillus  and  tetanus.    In  civil  practice,  which  deals  mainly  with  pistol- 

FiG.  24. 


Experimental  gunshot  fractures  with  .30  and  38  calibre  bullets  at  high  velocity.    (U.S.  Army 

Med.  Museum. 

shot  wounds,  the  results  now  obtained  are  good.  A  pistol-shot  wound 
is  usually  surgically  clean,  and  if  not  officiously  treated  may  be  con- 
fidently expected  to  heal  kindly;  a  piece  of  the  clothing  is  rarely  carried 
in  by  the  bullet  and  in  most  cases  all  that  is  necessary  is  to  clean  the 
surface  and  the  orifice  of  the  wound  and  apply  a  dressing.  The  bullet 
may  be  left  to  heal  in  unless  the  wound  is  large  and  ragged.  Late 
hemorrhages,  due  to  the  sloughing  of  bruised  vessels,  sometimes  occur. 

Displacements. 

The  relations  of  the  two  principal  fragments  produced  by  fracture 
of  a  bone  may  be  altered  in  various  ways,  which  Malgaigne  cla.ssified 
under  six  heads.  The  classification  has  been  generally  adopted,  with 
the  under.standing,  however,  that  a  fracture  usually  presents  a  combi- 
nation of  two  or  more  of  them,  and  that  there  is  an  additional  grouj) 
of  ca.ses  in  which  the  peculiarities  of  the  displacement  defy  classification. 

The  six  classes  group  displacements  according  to 

1.  The  transverse  axis  of  the  bone,  transverse  or  hderal  displacement. 

2.  The  long  axis  of  the  bone,  angular  displacement. 

3.  The  circumference  of  the  bone,  rotatory  displacement. 

4.  The  length  of  the  bone,  overriding. 

5.  Penetration  of  one  fragment  by  the  other,  impaction  or  crnshing. 

6.  Direct  longitudinal  separatio)i. 

1.  Transverse  or  lateral  displacement  may  take  place  forward,  back- 
ward, or  toward  either   side,  and  may  be  ])artial  or  conijilete.      Tuie 


38 


FRACTURES. 


transverse  displacement  is  rare  ;  it  is  usually  associated  with  overriding 
or  angular  displacement,  or  both  (Plate  II.,  Fig.  1). 

2.  Angular  displacement  may  vary  in  degree  from  a  slight  deviation 
to  a  right  angle,  or  even  more,  and  may  be  associated  with  so  com- 

FiG.  25. 


Fracture  of  the  clavicle. 


plete  and  distant  separation  of  the  broken  surfaces  that  the  fragments 
form  a  T  (Fig.  25).  It  may  be  produced  by  the  fracturing  violence, 
the  action  of  gravity,  or  the  contraction  of  the  muscles. 

3.  In  rotatory  displacement  one  fragment,  usually  the  lower,  turns 
about  its  long  axis,  while  the  other  fragment  remains  in  position. 


Fig.  26. 


YiG.  27. 


Fig.  28. 


Fracture  of  the  lower  end  of 
„   .   .        ...  the  radius.    Angular  disnlace- 

Rotatory  displacement  after  frac-    Fracture  of  both  bones  of  the    nient  of  the   lower    fragment 
ture  of  the  neck  of  the  femur.  leg,  with  overriding.  backward.    (R.  W.  Smith.) 

4.  Overriding  is  most  common  after  oblique  fracture  of  the  shaft, 
and  is  produced  by  various  causes,  such  as  a  continuation  for  a  moment 
after  the  fracture  of  the  force  that  has  produced  it,  the  tonicity  of  the 
muscles,  or  the  swelling  of  the  limb  due  to  inflammatory  reaction  and 


PATHOLOGY. 


39 


extravcasation  of  blood  beneath  the  deep  fascia,  which,  by  increasing  the 
transverse  diameters,  shortens  tlie  longitudinal  one. 

5.  Displacement  by  penetration  or  crushing  has  been  already  men- 
tioned as  the  impacted  variety  of  fracture.  Penetration  rarelv  takes 
place  without  a  change  in  the  direction  of  the  axes  of  the  fragments, 
because  of  diiferences  in  the  resistance  or  of  the  direction  of  the 
fracture. 

The  callus  found  after  consolidation  of  the  fracture  may  give  the  ap- 
pearance of  a  much  deeper  penetration  than  has  actually  taken  place ; 
thus,  in  Fig.  28  tlie  triangular  mass  of  S])ongy  tissue  on  the  side  is  not 
the  penetrated  epiphysis,  but  is  mainly  composed  of  callus  formed  by 
the  stripped-np  periosteum. 

6.  Direct  longitudinal  separation  is  seen  most  frequently  after  fracture 
of  the  patella,  and  is  then  due  partly  to  the  retraction  of  the  quadriceps 
and  partly  to  the  distention  of  the  joint  by  blood  and  exudate. 

Among  the  irregular  displacements,  those  which  do  not  fall  entirely 
within  the  above  classification,  may  be  mentioned  rotation  of  one  frag- 
ment about  its  transverse  axis,  as  in  some  fractures  of  the  neck  of  the 
humerus,  crossing  of  the  fragments  in  the  form  of  an  X,  and  the  inter- 
position of  a  bone  between  two  fractured  ones,  or  of  the  end  of  the 
shaft  between  its  separated  condyles. 

(B)  THE  SOFT  PARTS. 

The  periosteum  may  be  simply  loosened  from  the  surface  of  bone 
adjoining  the  fracture,  or  it  may  be  torn  across  throughout  the  whole 
or  only  a  portion  of  its  extent  at  or  near  the  line  of  fracture.  The 
first  form  (excluding  fractures  of  the  flat  bones)  is  found  only  in  fi-ac- 
tures  with  slight  displacement,  and  especially  in  the  young,  in  whom 
the  periosteum  is  thick  and  resistant.  Such  fractures  are  known  as 
subperiosteal.     They  may  be  recognized  or  inferred  from  the  youtli  of 

Fig.  29. 


'  Periosteal  bridge,"  diagrammatic. 


the  patient  and  the  slight  displacement  and  mobility  of  the  fragments 
Their  prognosis  is  exceptionally  good. 

Complete  rupture  of  the  periosteum  all  around  tlie  bone  is  probably 
infrequent  and  to  be  found  only  in  fractures  witii  great  displacement. 
Examination  of  fresh  specimens  and  of  the  })osition  and  slia])e  of  the 


40  FRACTVRES. 

callus  in  those  that  have  united  indicates  that  in  most  cases  the  conti- 
nuity of  the  periosteum  is  preserved  on  one  side,  the  continuous  portion 
being  stripped  off  one  of  the  fragments  for  some  distance  and  forming 
a  "  periosteal  bridge "  (Oilier),  which  unites  the  two  fragments  and 
takes  an  important  part  in  the  subsequent  repair.    (Plates  11.  and  III.) 

The  muscles  may  escape  injury  or  may  be  extensively  torn.  The 
neighborinof  connective  tissue  is  torn  and  infiltrated  with  blood  from  its 
own  vessels  or  from  those  of  the  broken  bone.  Injury  to  important 
vessels  and  nerves  is  rare ;  it  will  be  described  under  Complications, 
Chapter  VI. 

The  skin  may  be  torn  by  the  original  violence  or  by  the  sharp  end 
of  a  fragment,  or  it  may  be  so  bruised  by  the  original  violence  or  so 
pressed  upon  by  a  displaced  fragment  that  it  subsequently  sloughs. 
These  lesions  of  the  skin  may  communicate  with  the  seat  of  fracture 
(compound  fracture),  or  may  be  at  a  distance  therefrom  and  without 
influence  upon  its  course,  except  so  far  as  they  may  interfere  with  the 
application  of  splints.  Discoloration  of  the  skin  due  to  extravasated 
blood  beneath  almost  invariably  appears  after  a  day  or  two,  and  may 
be  widespread.  Large  blebs  filled  with  dark,  blood-stained  serum  fre- 
quently appear  upon  the  limb  near  the  fracture  by  the  second  or  third 
day. 


PLATE  II 


Fig.  1.  —  Fracture   of  Forearm,  Six  "Weeks  Old,  showing  Ossification 
along  Periosteal   Bridge. 


Fig.  2.  — Humerus,  Two  Years  after  Frpcture.     Growth  of  Bone  along 
Periosteal  Bridge. 


PLATE  III 


Same  as  Plate   II,  Fig.  2.     Injury  reeenl. 


CHAPTER    III. 

ETIOLOGY. 

Predisposing     Causes — Determining    Causes— Spontaneous     and     Pathological 
Fractures — Intra-uterine  Fractures  and  Fractures  During  Delivery. 

The  causes  of  fracture  may  be  grouped  uuder  two  heads:  A.  The 
predmposlng  causes;  B.    The  immediate  or  determining  causes. 

The  Predisposing  Causes 

are  of  three  kinds  :  (1)  the  external,  (2)  the  normal  or  physiological, 
and  (3)  the  pathological.  Most  of  the  latter,  which  consist  in  a  local 
or,  more  rarely,  a  general  diminution  of  the  strength  or  an  actual  de- 
struction of  the  bone  by  a  local  or  general  disease,  will  be  considered 
under  the  head  of  Spontaneous  or  Pathological  Fractures. 

The  external  predisposing  causes  are  those  incidental  to  various  occu- 
pations and  modes  of  life  which  involve  greater  exposure  to  deter- 
mining causes  ;  they  account  for  the  great  excess  of  fractures  in  males 
over  those  in  females  between  youth  and  old  age,  and  for  their  rarity 
in  young  children. 

The  normal  or  physiological  causes  are  those  which  have  their 
origin  in  the  position  and  functions  of  the  different  bones.  The 
bones  of  the  skull  and  chest  are  broken  when  the  violence  against 
which  they  are  designed  to  protect  the  enclosed  viscera  is  too  great  for 
their  power  of  resistance  ;  the  use  of  the  arms  in  many  occupations 
exposes  them  to  fracturing  violence,  and  they  and  the  lower  limbs  are 
broken  in  falls  all  the  more  easily  because  of  the  contraction  of  the 
muscles  by  which  they  are  stiffened  to  protect  the  body  against  the 
shock.  In  like  manner  the  normal  curves  in  single  or  associated  bones 
— e.  g.,  the  clavicle  and  spinal  column — which  su])ply  an  elasticity 
that  is  protective  of  the  viscera  increase  their  liability  to  fracture. 

Interstitial  atrophy  of  the  bones,  which  is  so  common  a  senile  change, 
is  undoubtedly  the  cause  of  the  greater  relative  frequency  of  fractures 
in  the  old  ;  and  its  agency  becomes  all  the  more  apparent  when  the 
usual  withdrawal  of  the  aged  from  the  occupations  which  most  expose 
to  fracture  is  taken  into  account.  This  atrophy  consists  in  thinning  of 
the  cortex  of  the  shafts  and  of  the  trabeculse  of  the  spongy  portions 
and  of  the  short  bones,  not  in  a  relative  increase  of  the  lime  salts  in 
the  bone  tissue  itself,  as  was  long  supposed.  It  is  an  actual  diminution 
of  the  bone  substance  and  a  corresponding  increase  of  the  fat  and  other 
soft  parts  contained  in  it.  In  the  old,  and  when  not  extreme,  it  may 
be  classed  as  a  normal  predisposition  to  fracture,  but  when  it  appears 
prematurely  or  reaches  an  extreme  degree  it  must  be  deemed  })atholog- 
ical  and  classed  with  other  similar  atrophies  whose  nature  and  causes 
are  not  well  understood. 

(41) 


42  FRACTURES. 

The  inherited  or  early  developed  liability  to  fracture  which  has  been 
observed  in  certain  individuals  and  families  who  were  in  other  respects 
normal  is  probably  the  result  of  a  similar  scantiness  of  the  bone  tissue. 
Of  this  inherited  liability  Gurlt  gives  three  examples,  extending  in 
one  over  four  generations,  in  the  others  over  three.  One  of  the  patients 
suffered  fourteen  fractures,  and  another  thirteen,  before  either  reached 
the  age  of  thirteen  years.  All  united  promptly.  He  gives  also  three 
cases  of  a  congenital  but  not  inherited  liability  to  fracture  in  families. 
One  girl  suffered  thirty-one  fractures  of  the  thigh,  leg,  and  arm  between 
the  ages  of  three  and  fourteen  years ;  her  sister  had  nine  before  she  was 
six  years  old.  Not  infrequently  individuals  have  developed  in  early 
or  middle  life  a  noticeable  fragility  of  the  bones  without  any  other 
change  that  would  indicate  a  general  deterioration  or  disease.  Thus, 
Bio-gs  ^  reports  a  case  of  twenty-two  fractures,  all  but  one  of  the  arm 
or  thigh,  between  the  ages  of  twenty  and  thirty  years  in  a  man  who  had 
suffered  none  before  or  after. 

Immediate  or  Determining  Causes  of  Fractures. 

These  are  of  two  kinds  :  (1)  External  violence,  and  (2)  muscular 
action,  the  latter  exerted  by  muscles  connected  more  or  less  directly 
with  the  bone  that  is  broken. 

1.  Fractures  by  External  Violence.  The  division  of  these  into  two 
classes,  of  which  one  is  called  fractures  by  direct,  the  other  fractures 
by  indirect,  violence  is  based  upon  clinical  differences  often  of  ex- 
treme importance,  and  not  simply  upon  mechanical  differences  in  the 
mode  of  transmission  and  in  the  effect  of  the  applied  force.  This 
relieves  us,  therefore,  from  the  necessity  of  examining  the  latter  ques- 
tions with  their  many  obscure  factors  and  complex  relations,  and  makes 
the  definitions  simple.  A  fracture  by  direct  violence  is  one  in  which 
the  bone  is  broken  immediately  under  the  point  upon  the  surface  where 
the  fracturing  force  is  exerted  ;  and  a  fracture  by  indirect  violence  is 
one  in  which  the  fracture  takes  place  at  a  distance  from  that  point. 
The  most  important  clinical  difference  between  the  two  varieties  de- 
pends upon  the  injury  to  the  overlying  soft  parts  in  the  one  case  and 
the  absence  of  such  injury  in  the  other. 

The  skin  is  not  always  broken  in  fractures  by  direct  violence,  even 
when  the  vulnerant  force  has  been  great  and  the  injury  to  the  soft  parts 
under  the  skin  extensive,  but  it  may  have  been  so  injured,  even  if  it 
shows  no  marks  of  violence,  that  it  will  slough.  On  the  other  hand, 
the  blow  may  break  the  skin  at  the  point  M'here  it  is  received  and  pro- 
duce fracture  indirectly  at  a  greater  or  less  distance,  the  bone  yielding 
at  its  point  of  least  resistance  and  not  at  that  where  the  force  is  directly 
exerted. 

The  fracturing  force  may  be  applied  directly  or  indirectly  to  the  bone, 
to  crush  or  break  it,  or  obliquely  to  its  long  axis,  or  as  torsion,  or  as 
avulsion.  Examples  of  the  first  are  furnished  by  falls  upon  the  feet 
with  fracture  of  the  calcaneum,  gunshot  wounds,  and  crushing  of  the 
lower  end  of  the  radius  in  a  fall  upon  the  hand  ;  of  the  second  by  most 
1  Biggs:  Univ.  of  Penn.  Bulletin,  1903,  No.  12. 


ETIOLOGY.  43 

fractures  of  tlie  shafts  of  long  bones ;  of  the  third  by  some  fractures 
of  the  leg  Avhcn  the  foot  is  fixed  and  the  body  turned  forcibly  about  it; 
and  of  the  fourth  by  some  fractures  of  the  lower  end  of  the  humerus 
by  forced  abduction  of  the  forearm,  by  some  of  the  internal  malleolus 
in  eversion  of  the  foot,  and  by  some  of  the  patella  in  forced  flexion  of  the 
knee  when  its  normal  range  of  motion  has  been  limited  by  previous 
injury. 

Indirect  fractures  are  by  far  more  common  in  long  bones  than  in  the 
short  spongy  ones,  because  of  their  proportions  and  functions.  The 
principle  of  their  production  is  that  of  the  transmission  of  a  force 
along  a  bone  or  set  of  bones  made  rigid  by  ligamentary  attachments 
or  muscular  contraction  in  such  manner  that  it  is  resolved  into  forces 
acting  in  two  or  more  directions,  one  of  which  crosses  the  long  axis 
of  the  bone  and  acts  as  if  it  had  been  applied  directly  at  the  point  of 
least  resistance  in  a  transverse  direction.  The  effect  is  greatly  modi- 
fied by  the  anatomical  structure  and  form  of  the  bone,  the  attitude  of 
the  limb,  the  contraction  of  the  muscles,  and  the  direction  of  the  blow. 
Thus,  a  fall  upon  the  hand  may  break  the  bones  of  the  forearm,  the 
humerus,  or  the  clavicle;  a  fall  upon  the  foot  may  fracture  the  calca- 
neum  by  direct  violence,  or  the  bones  of  the  leg,  the  thigh,  or  even 
the  vertebral  column  or  skull  by  indirect  violence. 

The  best  example  of  the  fracture  of  short  bones  by  indirect  violence 
is  furnished  by  the  spinal  column,  the  bones  of  which,  considered  as  a 
group,  constitute  a  long  bone  with  several  curves,  the  forcible  exag- 
geration of  which  produces  fracture. 

2.  Fractures  by  Muscular  Action.      Under  this  head  are    included 
only  those  fractures  in  which  the  rupturing  force  is  exerted  by  the 
muscles  alone,  without   the  aid  of  any  external  violence.     It  is,  of 
course,  evident  that,  if  an  individual   breaks  his  skull  or  a  limb  by 
running  or  striking  against  a   solid  object,  the  force  that  causes  the 
fracture  is  developed  by  the  action  of  his  muscles;  but  the  mechanism 
is  the  same  as  if  he  had  fallen  from  a  height,  or  as  if  his  body  was  at 
rest  and  the  object  with  which  he  has  come  into  contact  was  in  motion. 
And   in    many  other  cases  the  distinction  is  somewhat  arbitrary  and 
rather   clinical   than   mechanical,  for  often  in  fracture  by  external  vio- 
lence resistance  to  movement  of  the  bone  in  the  direction  impelled  by 
the  external  force  is  supplied  by  the  muscles,  and  without  that  resist- 
ance fracture  would  not  occur.      The  conditions  are  practically  the  same 
as  if,  the  distal  end  of  the  limb  being  held  stationary,  the  muscles  were 
sharply  contracted  in  an  attempt  to  move  it.     Thus,  a  man  holds  his 
arm  outstretched  while  another  seeks  to  lower  it  by  striking  the  fore- 
arm, and  the  humerus  breaks  below  the  insertion  of  the  deltoid  ;  or  a 
man  pushes  with   his   foot,  the   knee   being  partly  flexed,  his  foot  slips 
and  the  patella  is  broken  by  the  tearing   away  of  its  lower  portion   in 
the  sudden  flexion  of  the  knee,  the  upper  part  being  held  stationary  by 
the  tense  quadriceps.      Strictly  speaking,  only  those  cases  are  considered 
to  be  fractures  by  muscular  action  in  which  the  action  is  exerted  directly 
by  the  muscles   upon  the  bones  to  which  they  are  attached  (mediately 
or  immediately),  either  as  direct  traction,  as  in  fracture  of  the  patella 
4 


44  FRACTURES. 

or  of  the  olecranou,  or  obliquely,  or  in  torsion  against  resistance,  or  by 
sudden  muscular  arrest  of  the  rapidly  moving  limb,  as  in  throwing,  or 
in  striking  or  kicking  at  an  object  and  missing  it. 

Some  authors  have  expressed  the  opinion  that  no  bone  can  be  broken 
by  simple  muscular  contraction  unless  it  has  previously  undergone 
some  change  that  has  diminished  its  strength ;  but  this  opinion  must 
be  looked  upon  as  an  attempt  to  explain  away  by  an  unfounded,  or  at 
least  an  unproved,  assumption  a  difficulty  which  does  not  really  exist. 
It  is  no  more  logical  to  claim  that  such  a  change  has  preceded  every 
fracture  by  muscular  action  than  it  would  be  to  make  the  same  claim 
for  fractures  by  external  violence ;  it  can  rest  only  upon  the  assiimp- 
tit)n  that  the  power  of  resistance  of  a  normal  bone  is  superior  to  any 
force  that  a  muscle  or  group  of  muscles  can  exert  upon  it,  even  under 
extreme  and  unusual  circumstances;  whereas,  on  the  contrary,  nature's 
precautions  and  adaptations  are  calculated  upon  the  basis  of  the  prob- 
able, not  of  the  exceptional.  Such  a  position  may  be  taken  with  pro- 
priety concerning  all  fractures  produced  by  slight  causes  in  the  old, 
the  diseased,  the  cachectic,  or  in  those  who  have  suffered  pain  at  the 
point  of  fracture  for  some  time  previous  to  the  accident;  but  it  is 
entirely  unsupported  by  proof  in  the  rarer,  but  still  sufficiently  numer- 
ous, cases  of  the  fracture  of  the  shaft  of  a  long  bone  produced  by  a 
violent  effort  in  a  healthy  athletic  man,  and  in  the  common  ones  of 
fracture  of  the  patella. 

The  effect  of  muscular  action  is  manifested  in  all  the  degrees  of 
varying  importance  between  its  relatively  unimportant  additions  to 
the  effects  of  external  violence  and  those  cases  in  which  it  is  the  sole 
agent  of  the  fracture  of  a  healthy  bone.  The  intermediate  degrees 
are  presented  by  those  fractures,  usually  of  weakened  bones,  in  which 
moderate  muscular  action  has  acted  either  alone  or  combined  with 
slight  external  violence.  In  the  first  case,  when  the  power  of  the 
muscle  is  exerted  in  the  same  direction  as  the  external  violence,  it 
increases  the  fracturing  force  by  just  so  much  ;  and,  by  prolonging  its 
effect  after  the  fracture  has  been  made,  it  also  increases  the  displace- 
ment of  the  fragments  and  the  laceration  of  the  soft  parts.  The  prin- 
cipal interest  of  the  intermediate  cases  is  connected  with  the  cause  of 
the  exceptional  fragility  of  the  bone,  and  is  considered  in  the  following 
section — Spontaneous  and  Pathological  Fractures. 

The  commonest  examples  of  fracture  by  muscular  action  alone  are 
furnished  by  the  patella ;  other  apophyses  and  tuberosities  to  which 
powerfid  muscles  are  attached — the  olecranon,  greater  tuberosity  of 
the  humerus,  coracoid,  acromion — furnish  them  much  more  rarely. 

Of  the  long  bones  the  humerus  is  tlie  one  most  frequently  broken 
in  this  manner;  out  of  85  cases  of  fracture  of  the  limbs  by  muscular 
action  collected  by  Gurlt,^  57  were  fractures  of  the  humerus,  15  of  the 
thigli,  8  of  the  leg,  and  5  of  the  forearm.  Ashhurst- collected  81  cases 
of  fracture  of  the  humerus  :  24  by  torsion,  57  by  a  blow.  The  mech- 
anism seems  in  most  cases  to  be  the  same  as  in  indirect  fracture  ;  in 
some  the  fracture  takes  place  at  the  insertion  of  the  muscle,  and  in 

'  Gurlt:  Loc.  ciL,  vol.  i.  p.  232.     -^  Ashhurst;  Univ.  of  Penn.  Med.  Bull.,  Feb.  1906. 


ETIOLOGY.  45 

others  the  elements  are  too  complex  and  too  conjectural  to  be  explained 
theoretically.  In  a  comparatively  small  number  of  cases  the  fracture 
lias  been  caused  by  reflex  spasms  in  limbs  that  had  long  been  paralyzcid 
or  by,  the  convulsions  of  epilepsy  or  tetanus,  but  usually  the  cause  is  a 
violent  voluntary  muscular  effort  to  avoid  a  fall,  to  throw  a  stone,  or  to 
lift  a  heavy  object.  The  following  cases  taken  from  Gurlt  illustrate  the 
different  forms  and  the  methods  by  which  they  may  be  produced.  It 
must  be  remembered  that  fractures  produced  during  convulsions  need 
to  be  closely  examined  in  order  not  to  overlook  the  possible  addition  of 
external  violence  by  a  fall  from  the  bed  or  by  a  blow. 

In  a  negro  boy,  twelve  or  thirteen  years  of  age,  aflPected  with  teta- 
nus, both  thigh  bones  were  broken  "at  the  neck,"  possibly  just  below 
the  trochanter,  by  the  contraction  of  the  muscles,  and  the  fragments 
forced  through  the  skin  on  the  outer  side  of  the  limb. 

An  athletic  man,  thirty-four  years  old,  accustomed  to  lift  heavy 
weights,  broke  his  humerus  with  an  audible  snap,  just  below  the  inser- 
tion of  the  deltoid,  by  the  effort  made,  on  a  wager,  to  throw  a  stone 
weighing  about  two  ounces  the  distance  of  a  hundred  yards.  Recovery 
in  six  weeks. 

Gurlt  gives  11  cases,  and  Ashluirst  (loc.  cit.)  24,  in  which  the  humerus 
was  broken  during  that  trial  of  strength  in  which  two  men  place  their 
elbows  upon  a  table,  clasp  hands  with  the  forearms  parallel  and  ver- 
tical, and  strive  to  force  each  other's  hand  backward. 

Fractures  of  the  femur  may  occur  at  any  point  of  the  shaft,  and  in  the 
recorded  cases  have  been  the  result  of  an  attempt  to  kick,  to  avoid  a  fall, 
or  to  rise  from  the  ground  on  one  foot,  or  of  cramps,  excited  in  one  case 
by  drawing  on  a  tight  boot  and  in  another  by  turning  in  bed. 

A  man,  thirty-six  to  thirty-eight  years  old,  of  middle  size  and  great 
muscular  power,  broke  his  thigh  at  the  junction  of  its  upper  and  middle 
thirds  by  kicking  at  and  missing  his  servant. 

Van  Oven  described  before  the  Royal  Medical  and  Surgical  Society 
a  fracture  of  the  thigh  sustained  by  himself.  He  was  fifty-six  years 
old,  healthy  and  strong,  and  free  from  taint  of  cancer,  scrofula,  syph- 
ilis, etc.  He  was  awakened  by  a  sharp,  cramp-like  pain  above  the 
knee,  and  as  he  felt  the  part  with  his  hand,  and  noticed  that  the  muscle 
was  tense,  he  heard  a  snap,  followed  by  relaxation  of  the  muscle,  crepi- 
tus, and  diminution  of  the  pain.  Examination  showed  a  transverse 
fracture  of  the  femur  three  inches  above  the  knee.  Complete  recovery 
in  four  months. 

A  cavalryman,  twenty-nine  years  old,  while  trying  to  rise  from  a 
sitting  posture  on  the  ground  without  the  aid  of  his  hands,  broke  his 
right  thigh  at  its  middle. 

Gurlt's  eight  cases  of  fracture  of  the  leg  comprise  four  of  botli  bones, 
one  of  the  tibia,  and  three  of  the  fibula  alone,  the  latter  being  fractures 
at  the  upper  end  of  the  bone  by  the  contraction  of  the  biceps. 

A  small,  rather  corpulent  woman,  forty-five  years  old,  slip]ic(l  on 
the  left  foot  wliile  descending  some  steps,  made  a  violent  effort  with 
the  right  leg  to  avoid  a  fall,  felt  at  once  a  severe  jiain  in  the  latter,  and 
fell  in  a  sitting  posture.  An  immediate  examination  showed  a  fracture 
of  both  bones  at  the  middle  of  the  leg. 


46  FRACTURES. 

A  woman,  fifty-two  years  old,  mistook  a  door  leading  into  the  cellar 
for  one  opening  into  a  closet,  and,  recognizing  the  mistake  as  she  put 
her  right  foot  forward,  drew  herself  instinctivelv  backward,  and  felt 
at  the  same  moment  something  snap  in  her  left  leg,  upon  which  the 
weight  of  her  body  rested.  She  fell  and  rolled  down  the  steps.  A 
fracture  of  the  left  fibula  just  below  its  head  was  found. 

Fracture  of  either  or  both  bones  of  the  forearm  has  been  caused  by 
the  Avringing  of  wet  clothes  and  in  shovelling.  A  healthy  girl,  eighteen 
years  old,  while  wringing  clothes,  felt  a  sudden  sharp  pain  on  the  inner 
side  of  the  forearm  above  the  wrist.  Three  days  afterward  a  fracture 
of  the  ulna,  two  and  one-half  inches  above  the  wrist,  was  recognized. 

A  woman,  thirty  years  old,  broke  the  radius  in  its  lower  third  with 
severe  pain  while  wringing  two  heavy  towels. 

Fractures  of  the  clavicle  have  been  caused  by  the  effort  of  raising  a 
heavy  object,  shovelling,  and  striking  backward  or  with  a  whip. 

Fractures  of  one  or  more  ribs  are  not  infrequently  caused  by  violent 
coughing,  especially  in  the  consumptive.  The  sternum  has  been  broken 
in  four  recorded  cases  by  the  violent  straining  and  bending  backward 
of  the  body  during  the  expulsive  efforts  of  parturition,  and  there  are 
several  cases  of  fracture  of  the  cervical  vertebrse  by  muscular  action 
alone,  and  of  the  scapula. 

Hilton  reports  the  case  of  a  man  who  had  broken  a  rib  by  muscular 
action  while  trying  to  mount  a  spirited  horse. 

A  primipara,  twenty-four  years  old,  taken  in  labor,  sought  to  hasten 
delivery  by  forcible  expulsive  efforts,  bending  backward  and  resting 
on  her  elbows  and  heels  ;  she  felt  a  sudden  sharp  pain  and  a  snap  in  the 
middle  of  the  breast,  and  said  at  once  that  something  had  broken  there. 
She  died  of  peritonitis,  and  at  the  autopsy  a  transverse  fracture  of  the 
sternum  was  found,  one  and  one-half  lines  above  the  junction  of  its 
body  and  the  manubrium. 

A  soldier  dived  into  a  river,  and,  not  reappearing,  was  sought  for 
and  brought  out.  His  body  showed  no  trace  of  external  violence,  but 
there  was  paralysis  of  all  the  limbs,  loss  of  sensation,  pain  at  the  pos- 
terior and  lower  parts  of  the  neck,  priapism,  frequent  desire  to  urinate. 
He  said  that  as  he  dived  he  saw  the  water  was  too  shallow,  and  in  the 
effort  to  avoid  striking  against  the  bottom  he  jerked  his  head  sharply 
backward  and  at  once  lost  consciousness.  He  died  the  same  night,  and 
the  autopsy  showed  a  transverse  fracture  of  the  body  of  the  fifth  cer- 
vical vertebra  a  little  below  its  centre.  A  number  of  similar  cases 
have  been  reported. 

A  servant  engaged  in  preparing  a  lamp  raised  his  arm  quickly  to 
arrest  the  action  of  an  escaping  spring  and  felt  something  give  way  in 
it.  The  arm  fell  powerless  by  his  side,  and  the  greater  portion  of  the 
acromion  was  found  to  have  been  broken  off. 

I  have  seen  two  fractures  of  the  coracoid  process  by  forcible  con- 
traction of  the  muscles  of  the  arm. 


ETIOLOGY.  47 

Spontaneous  and  Pathological  Fractures. 

The  term  spontaneous  is  used  to  indicate  that  the  violence,  external 
or  muscular,  which  has  produced  the  fracture  is  much  less  than  that 
commonly  observed  in  that  form ;  and  the  term  pathological  to  indi- 
cate a  preceding  abnormal  change  in  the  fractured  bone  by  which 
its  strength  has  been  diminished.  It  has  become  common  to  use  the 
terras  interchangeably,  because  the  slight  violence  indicated  by  the 
first  is  efficient  to  fracture  only  when  the  change  indicated  by  the 
second  is  present. 

It  is  noteworthy  that  the  pain  accompanying  or  following  the  frac- 
ture is  often  very  slight ;  fractures  of  ribs,  and  even  some  of  the  limbs, 
have  passed  unrecognized  until  the  autopsy.  The  pathological  condi- 
tion known  as  general  atrophy  or  rarefaction  of  the  bone,  or  osteopo- 
rosis, and  which  has  been  referred  to  as  senile  atrophy,  may  appear 
prematurely  or  may  have  its  origin  in  other  causes  than  senility,  such 
as  paralysis,  locomotor  ataxia,  diabetes,  pregnancy,  and  osteomalacia. 
It  is  worthy  of  note  that  in  not  a  small  proportion  of  cases  union  takes 
place  promptly.  In  most  of  the  cases  which  furnish  autopsies  the  bones 
are  found  softened  and  reduced  to  a  shell  by  absorption  from  within, 
and  in  some  of  the  cases  suppuration  has  taken  place  at  the  fracture. 

It  has  been  noted  by  Bouchard  and  by  Verneuil  and  Verchere  that 
spontaneous  fracture  occasionally  ha])pens  in  the  diabetic,  and  that  the 
urine  shows  the  presence  not  only  of  sugar  but  also  of  phosphoric  acid 
in  quantities  that  suggest  its  origin  in  a  decalcification  of  the  bones. 
These  observations  have  been  confirmed  by  Isch-Wall  (quoted  by 
Ricard),  who  also  found  the  phosphoric  acid  present  in  some  patients 
affected  with  cancer.  In  nine  cases  of  spontaneous  fracture  in  the 
dial)etic  reported  by  Verchere  union  was  greatly  delayed. 

The  following  cases  represent  different  varieties  : 

A  woman,  seventy-two  years  old,  had  both  thighs  broken  by  kneel- 
ing in  church,  and  the  humerus  by  the  efforts  of  bystanders  to  lift  her 
up.  Another  broke  her  clavicle  by  putting  her  arm  about  the  nurse's 
neck  and  trying  to  turn  herself  in  bed  (Gurlt). 

A  woman,  forty-five  years  old,  the  mother  of  two  children,  suffered 
a  great  deal  of  pain  in  her  bones  after  the  birth  of  her  second  child, 
and  became  so  helpless  that  she  could  not  get  into  or  out  of  bed  with- 
out aid.  She  broke  each  thigh  below  the  trochanter  by  stumbling 
against  the  bedpost  in  one  case  and  by  turning  in  bed  in  the  other. 
B<jth  united  with  marked  angular  displacement,  and  at  the  autopsy  the 
bones  of  the  thigh  and  pelvis  were  found  to  be  so  light  that  they  floated 
in  water  and  could  be  crushed  by  pressure  with  the  finger.  The  cor- 
tical layer  of  the  femur  was  as  thin  as  an  egg-shell,  the  medullary 
canal  enlarged,  traversed  here  and  there  by  delicate  plates  of  bone,  and 
filled  with  a  grumous,  semifluid  mixture  of  blood  and  marrow  (Gurlt). 

A  man,  sixty  years  old,  broke  his  femur  in  the  middle  third  by 
stumbling,  without  falling.  He  died  a  fortnight  later,  and  I  found  an 
enormous  calculus  in  each  kidney. 

Saviard  saw  in  1690  a  woman,  about  thirtv  vears  old,  who  had  suf- 


48  FRACTURES. 

fered  for  four  months  with  severe  pains  throughout  the  body,  increased 
by  movements,  and  without  fever.  Three  months  later  she  had  become 
bedridden,  and  her  bones  had  become  so  friable  that  most  of  them  were 
broken,  and  she  could  not  be  moved  without  causing  a  new  fracture. 
She  lived  ten  months  in  this  condition,  and  the  autopsy  showed  frac- 
tures of  almost  every  bone  in  her  body.  The  structure  of  the  bones 
was  so  delicate  that  they  could  not  be  pressed  between  the  fingers  with- 
out breaking  into  small  pieces ;  the  marrow  was  red,  the  muscles  pale, 
the  joints  and  cartilages  unchanged. 

In  a  case  under  my  care  the  tibia  appeared  to  have  been  weakened 
by  an  osteitis  set  up  by  a  blow  and  a  wound  of  the  soft  parts.  The 
wound  healed  in  three  weeks ;  a  fortnight  later  the  patient  returned 
with  a  compound  fracture  of  the  leg  at  the  scar,  caused  by  stepping 
down  a  distance  of  two  feet.  The  bone  could  be  plainly  seen  and  was 
rarefied.     Prompt  recovery. 

A  similar  friability  is  also  found  in  some  cases  of  old  unreduced 
dislocation,  due,  it  is  supposed,  to  lack  of  use.  The  condition  was 
shown  by  direct  examination  in  a  case  of  subcoracoid  dislocation  of  six 
weeks'  standing,  in  which  Guerin '  tore  oflP  the  forearm  in  an  attempt 
to  reduce.  The  ends  of  the  bones  were  rarefied  and  soft,  and  the  mus- 
cles softened  and  brown.  The  autopsy  showed  no  change  in  the  other 
portions  of  the  body. 

It  seems  probable,  however,  that  in  most  cases  in  which  fracture  has 
occurred  during  an  attempt  to  reduce  a  dislocation,  and  in  which  un- 
usual fragility  has  been  alleged  in  explanation,  the  force  exerted  upon 
the  bone  has  been  greater  than  the  surgeon  supposed,  because  of  the 
leverage  employed,  especially  in  rotation  of  the  limb. 

Disease  of  the  Nerve-centres.  In  1842  Davey  called  attention  to  the 
facility  with  which  fracture  sometimes  occurred  in  lunatics,  especially 
in  those  who  were  also  paralytic,  and  the  observation  has  been  abun- 
dantly confirmed,  Bruns  having  collected  more  than  sixty  reported 
cases. ^  Weir  Mitchell^  was  the  first  to  call  attention  to  the  frequency 
of  fractures  in  those  aifected  with  locomotor  ataxia,  and  suggested  that 
the  cause  might  lie  in  an  impairment  of  the  nutrition,  and  consequently 
of  the  strength,  of  the  bone  dependent  upon  the  disease  of  the  cord. 
Shortly  afterward  Charcot^  published  a  remarkable  case  of  multiple 
fractures  and  dislocations  in  an  ataxic  woman,  and  Bruns  ^  followed 
with  a  paper  upon  the  subject,  based  upon  thirty  cases  reported  within 
a  few  years.  He  finds  that  the  fractures  are  usually  multiple,  from 
two  to  six  in  number,  and  are  most  common  in  the  lower  limb,  espe- 
cially in  the  femur ;  the  frequency  is  equal  in  the  different  bones  of  the 
upper  extremity — clavicle,  humerus,  and  forearm.  Le  Dentu^  reported 
a  case  of  fracture  of  the  patella  in  a  tabetic  man  and  collected  six  reported 
cases.    He  says  the  repair  of  the  tabetic  fractures  is  exceptionally  rapid 

»  Guerin:  Bull,  de  la  Soc.  de  Chir.,  1864,  vol.  v.,  pp.  121  and  131. 

2  See  also  Baum:   Deutsche  Zeitschrift  fiir  Chir.,  vol.  99,  p.  1,  for  120  cases. 

3  Weir  Mitchell:  American  Journal  of  the  Medical  Sciences,  July,  1873,  p.  113. 

4  Charcot:  Arch,  de  Phys.,  1874,  p.   166. 

6  Bruns:  BerUn,  klin.  Wochenschrift,  1882,  p.  164. 

«  Le  Dentu:  Bull,  de  I'Acad.  de  Med.,  Nov.  26,  1912,  p.  431. 


ETIOLOGY.  49 

in  50  per  cent.,  and  fails  in  24  per  cent.,  and  that  repair  is  exclusively 
by  a  peripheral  callus. 

The  accident  seems  to  occur  more  frequently  in  the  earlier  than  in 
the  later  stages  of  the  nervous  disease,  and  the  predisposing  condition 
is  a  rarefaction  of  the  hone  marked  by  great  absorption  of  the  compact 
tissue,  increase  of  fat,  and  loss  of  inorganic  matter.  A  very  remark- 
able instance  of  the  earliness  of  this  change  is  given  by  Tillmann^  in 
the  report  of  three  cases  of  spiral  fracture  of  the  shaft  of  the  femur 
caused  by  the  effort  made  in  drawing  off  a  shoe.  The  patients  showed 
nothing  abnormal  at  the  time,  but  when  examined  three  and  half,  five, 
and  eight  years  later,  respectively,  locomotor  ataxia  existed. 

Rachitis.  Friability  due  to  rachitis  is  found  only  in  childhood,  for 
the  disease  is  one  which  involves  the  bones  only  during  their  period  of 
growth,  and  consists  essentially  in  the  prolongation  and  exaggeration 
of  the  embryonal  or  developmental  condition  of  the  shaft,  in  conse- 
cpience  of  which  its  strength  and  the  firmness  of  its  union  with  the 
epiphyses  are  diminished. 

Union  after  fracture  takes  place  rather  more  slowly  than  in  normal 
bone,  and  sometimes  fails  entirely.  The  callus  is  usually  large,  but, 
as  it  is  composed  of  the  same  soft  embryonal  tissue  M'hose  excess  is  the 
pathological  feature  of  the  disease,  it  is  lacking  in  firmness. 

Syphilis,  Mercurialism,  and  Rheumatism.  Syphilis  affects  the  organ- 
ism in  so  many  and  so  varied  forms,  and  causes  such  serious  bone 
lesions  in  its  later  stages,  that  it  is  not  strange  that  both  physicians  and 
patients  have  been  inclined  to  attribute  to  it  fractures  produced  by 
slight  causes  whenever  the  patient  was  or  had  been  affected  by  it. 
And  in  like  manner  those  who  saw  in  mercury  the  cause  of  the  bone 
lesions  of  syphilis  attributed  the  fractures  to  the  use  of  that  drug. 

When  we  remember  what  multitudes  of  people  have  contracted 
syphilis,  how  numerous  those  in  whom  it  has  caused  grave  lesions  of 
the  bones,  and  on  the  other  hand  how  few  are  the  cases,  excluding  sep- 
aration of  the  epiphyses  in  the  new-born,  in  which  it  can  even  be  sus- 
pected as  a  predisposing  cause  of  fracture,  it  is  evident  that  it  can  have 
but  little  influence  in  this  direction  ;  and  an  examination  of  the  alleged 
cases  shows  very  frequently  a  coexisting  constitutional  weakness  or  a 
cachexia  not  always  to  be  attributed  to  the  specific  disease  which 
creates  a  close  resemblance  between  these  cases  and  those  in  which  the 
atrophy.  If  locomotor  ataxia  is  a  late  manifestation  of  syphilis  its 
fractures  may  be  termed  syphilitic. 

Gurlt's  fifteen  syphilitic  cases  include  five  in  which  the  fracture  was 
preceded  by  severe  pain,  more  or  less  prolonged,  in  the  broken  bone, 
and  these  might  be  deemed  demonstrative  of  the  influence  of  syphilis 
did  we  not  possess  other  similar  cases  in  which  the  syphilitic  complica- 
tion does  not  exist.  Malgaigne,  indeed,  speaks  of  local  inflammation 
of  the  bone  as  a  frequent  and  too  much  neglected  predisposing  cause  of 
fracture,  adding  :  *'  I  give  this  name,  conjecturally,  to  an  affection 
which  manifests  itself  by  dull  pains  attributed  by  the  patient  to  some 
contusion  or  to  rheumatism,  rarely  sufficient  to  cause  a  general  reaction. 

1  Tillmann:  Berlin,  klin.  Wochenschrift,  1896,  No.  35. 

2  Malgaigne:  Loc.  cit.,  p.  22. 


50  FRACTURES. 

and  attracting  bnt  little  attention  until  some  slight  cause  produces  frac- 
ture at  the  point  it  occupies."    I  have  seen  several  such  cases. 

There  seems  to  be  no  reason  to  suppose  that  mercury  has  any  direct 
action  upon  the  bones  rendering  them  more  liable  to  fracture,  and  the 
most  that  can  be  claimed  is  that  its  excessive,  unskilful  use  will  cause 
a  deterioration  of  the  health,  which  may  result  in  an  atrophy  of  the 
bones  similar  to  that  found  in  old  age. 

Cancer  and  Sarcoma.  There  are  two  ways,  apparently,  in  A\hieh  the 
development  of  a  malignant  tumor  may  lead  to  fracture  :  either  the 
tumor  may  occupy  the  bone  itself,  primarily  or  secondarily,  and  destroy 
it  to  such  an  extent  that  the  slightest  force  is  sufficient  to  fracture  it, 
or  the  presence  of  the  tumor  elsewhere  may  induce  a  cachexia  which 
results  in  atrophy  of  the  bones.  The  following  cases  are  quoted  in 
illustration  : 

Louis  ^  was  called  to  see  a  nun,  sixty  years  old,  whose  arm  had  been 
broken  by  the  eflPorts  of  a  coachman  to  help  her  into  a  carriage.  Union 
did  not  take  place,  and  six  months  later,  while  seated  in  a  chair,  she 
broke  her  femur  by  letting  her  hand  fall  upon  it.  Louis,  seeking  the 
cause  of  this  fragility,  then  learned  that  the  patient  had  an  ulcerated 
cancer  of  the  breast. 

A  woman, ^  forty  years  old,  who  had  a  cancer  of  the  breast  for  some 
time,  with  well-marked  cachexia,  broke  her  right  femur  in  the  lower 
third  by  rising  from  a  chair.  She  was  taken  to  the  hospital,  and  there 
the  other  femur  was  broken  by  the  interne  as  he  was  preparing  to 
apply  a  bandage  to  the  first.  She  died  the  same  night,  and  at  the 
autopsy  cancerous  masses  were  found  in  the  spongy  tissue  and  in  the 
medullary  canal  at  the  points  of  fracture  and  elsewhere,  also  in  the 
vertebrae  and  cranial  bones. 

I  have  now  under  treatment  a  woman  thirty-one  years  old  who  broke 
her  left  femur  in  the  upper  third  by  stumbling,  without  falling.  For 
two  years  she  has  had  a  carcinoma  of  the  left  breast,  unulcerated  but 
involving  the  skin.  Two  months  later  there  was  a  large  mass  at  the 
seat  of  fracture,  and  on  moving  the  limb  crackling  (apparently  the 
breaking  of  small  pieces  of  bone)  could  be  plainly  felt.  Now,  a  month 
later,  there  seems  to  be  fairly  firm  union. 

In  thirty-two  cases  collected  by  Gurlt  in  which  the  position  of  the 
primary  tumor  is  noted,  it  occupied  the  mammary  gland  twenty-six 
times  (once  in  a  man);  and  of  the  entire  thirty-eight  cases  thirty-five 
were  women.  As  a  rule,  too,  the  affection  was  of  long  standing ;  in 
many  of  the  cases  the  tumor  had  returned  after  removal,  and  in  nine 
it  had  ulcerated.  The  humerus  and  femur  were  almost  exclusively 
affected,  but  very  unequally — twenty-six  fractures  of  the  femur  and 
seven  of  the  humerus.  Severe  localized  pain  in  the  bone  preceded  the 
fracture  in  a  number  of  cases. 

Heunion  took  place  in  one-fourth  of  the  cases,  and  in  at  least  three 
of  these  there  was  cancerous  degeneration  of  tiie  bone  at  the  seat  of 
fracture.     In  most  of  the  remaining  twenty-eight  cases  death,  due  to 

iMalgaigne:  Loc.  cit.,  vol.  i.  p.  14 

■^  Cruveilhier :  Anat.  Path.,  Livraison  xx,  PL  1,  Fig.  4. 


ETIOLOGY.  51 

the  pro2:ress  of  the  disease,  followed  so  soou  after  the  fracture  that  tlie 
bones  had  not  time  to  unite,  even  if  they  were  capable  of  doinu'  so. 

Hydatid  and  Other  Cysts.  There  are  a  few  instances  on  record  in 
which  the  unsuspected  development  of  a  hydatid  cvst  within  a  bone 
has  resulted  in  its  fracture  by  slight  violence  at  the  point  occupied  by 
the  oyst;  and  others  in  which  a  similar  result  has  been  prf)duced  bv 
the  occurrence  of  a  cystic  degeneration  of  unspecified  character  witliin 
the  bone.  These  causes  act  by  direct  absorption  of  the  cortical  lavcr 
of  the  bone,  and  their  action  is  purely  local. 

Osteomyelitis  favors  fracture  by  partial  destruction  of  the  bone,  but 
as  this  effect  is  accompanied  by  a  rapid  and  often  very  bulky  new- 
formation  which  makes  good  the  loss,  fractures  are  but  infrequentlv 
observed  except  in  the  course  of  operations  undertaken  for  the  cure  of 
the  disease  which  require  much  cutting  away  of  the  new  bone.  I 
have  seen  several  such  ;  their  importance  is  slight,  for  there  is  usuallv 
but  little  displacement,  and  repair  takes  place  within  the  usual  time. 

Intra-uterine  Fractures  and  Fractures  During-  Delivery. 

Fracture  of  a  limb  of  the  child  during  its  delivery  through  the  natural 
passages  of  the  mother  is  not  very  infrequent  and  is  usually  the  result 
of  manual  or  instrumental  interference.  Such  fractures  belong  to  the 
class  of  fractures  by  external  violence,  and  present  no  features  of 
special  interest ;  but  there  are  others  in  which  the  fracture  is  caused 
by  the  expulsive  eflPorts  of  the  mother  alone.  An  arm  or  a  leg  is 
engaged  between  the  body  of  the  child  and  the  rigid  parts  of  the 
mother,  and  the  humerus  or  the  femur  is  broken,  sometimes  with  an 
audible  snap,  as  the  child  is  forced  through  the  passage. 

Fractures  within  the  uterus  have  been  caused  in  a  few  cases  by  a 
bullet  or  sharp  instrument  that  has  at  the  same  time  perforated  the 
abdominal  wall  of  the  mother. 

The  possibility  of  the  occurrence  of  fracture  within  the  uterus  as 
the  result  of  external  violence  without  perforation  of  the  abdomen  of 
the  mother,  or,  in  some  cases,  of  unknown  causes,  has  been  proved  by 
the  birth  of  children  presenting  fractures  of  different  bones  in  various 
stages  of  repair.  It  is  not  always  easy  to  say,  when  a  child  is  born 
with  a  fracture,  whether  it  Avas  caused  during  delivery  or  at  an  earlier 
period,  or  whether  it  was  due  to  external  violence  or  to  the  contractions 
of  the  uterus.  And,  further,  it  is  not  always  possible  to  say  whether 
an  ai)parent  fracture  is  actually  one  or  only  a  malformation,  a  defect 
of  ossification  or  of  development,  or  a  separation  of  the  epiphysis  due 
to  syphilis.  Gurlt  collected  eight  cases  in  which  the  causal  relation 
between  an  injury  received  by  the  mother  during  pregnancy  and  the 
fracture  observed  in  the  child  seemed  to  him  to  be  clearly  demon- 
strated, and  twenty-tive  others  in  which  more  or  less  doubt  existed  as 
to  the  cause  of  the  fracture  or  the  character  of  the  lesion.  The  injury 
in  the  first  eight  cases  was  either  a  fall  from  a  height  or  a  violent  blow 
upon  the  abdomen  ;  and  the  bones  broken  were  those  of  the  thigh,  leg, 
arm,  and  forearm,  and  the  chivicle. 


62  FRACTURES. 

The  other  group  includes  some  in  which  an  undoubted  fracture 
existed,  but  with  no  history  of  external  violence,  and  some  in  which 
the  coexistence  of  malformations  threw  some  doubt  upon  the  character 
of  the  supposed  fracture,  and  others  in  which  the  fractures  were  so 
numerous  and  so  symmetrical  that  they  must  have  depended  upon  some 
general  cause,  syphilis  or  rachitis,  acting  possibly  upon  the  epiphyseal 
cartilages. 


CHAPTER  IV. 

EARLY  SYMPTOMS  AND  DIAGNOSIS. 

The  symptoms  produced  by  a  fracture  are  divided  into  two  groups : 
the  objective  or  positive,  those  which  can  be  directly  observed  Ijy  the 
surgeon,  and  the  subjective  or  rational,  those  for  his  knowledge  of  which 
he  has  to  depend  more  or  less  completely  upon  the  statements  of  the 
patient.  The  former  include  defarmity  of  the  limb  or  part,  abnormal 
mobility  at  the  point  of  fracture,  and  crepitus.  The  second  group 
includes  loss  of  function,  pjain,  and  history  of  the  case  and  of  the 
patient. 

Objective  Signs. 

Deformity.  This  term  is  here  employed  in  its  widest  sense,  to  include 
changes  in  tlie  relations  of  the  fragments  of  the  bones  to  each  other 
and  the  modifications  in  the  appearance  of  the  limb  or  part  of  the  body 
produced  by  those  changes,  by  the  effusion  of  blood,  and  by  the  later 
inflammatory  processes. 

The  changes  in  the  relations  of  the  fragments  to  each  other  have 
been  described  in  detail  under  Displacements.  Many  of  them  are  so 
marked  that  they  are  recognizable  by  simple  inspection  of  the  part, 
while  others  are  brought  to  light  only  by  careful  palpation  and  by  meas- 
urements compared  with  those  of  the  opposite  limb.  These  measure- 
ments are  used  in  practice  only  to  recognize  displacements  by  which  a 
limb  is  shortened  or  the  diameters  of  an  articular  extremity  modified. 
In  a  few  places  practically  normal  relations  exist  which  may  take  the 
place  of  comparison  with  the  opposite  limb  :  such  are  those  of  the  great 
trochanter  of  the  femur  to  a  line  drawn  from  the  tuberosity  of  the 
ischium  to  the  anterior  superior  spine  of  the  ilium,  and  those  of  the 
styloid  process  of  the  radius  to  that  of  the  ulna,  both  of  which  may 
be  used  with  confidence  in  cases  of  fracture  of  the  neck  of  the  femur 
or  of  the  lower  extremity  of  the  radius  respectively. 

The  chief  difficulty  in  employing  mensuration  is  that  of  finding 
well-defined  points  upon  the  skeleton  between  which  the  measurements 
can  be  made.  Those  employed  in  fractures  are  bony  prominences  or 
edges  sufficiently  near  the  surface  to  be  clearly  felt,  but  as  they  are  all 
more  or  less  rounded,  absolute  accuracy  in  measuring  the  distance  is 
impossible. 

Another  cause  of  uncertainty  or  of  error  lies  in  tlie  normal  asym- 
metry, the  difference  not  due  to  traumatism  or  disease,  which  has  been 
found  occasionally  to  exist,  and  which  sometimes  is  very  notable,  as 
much  as  an  inch  and  a  half  in  the  lower  limbs. 

(53) 


64  FRACTURES. 

Other  sources  of  difficulty  and  error  are  found  in  the  swelling  of  the 
soft  parts,  which  may  prevent  the  tape  from  being  drawn  straight,  and 
in  the  varying  angles  between  the  axis  of  the  limb  and  the  line  of 
measurement.  The  first  is  not  likely  to  be  great  or  to  be  overlooked  ; 
but  the  latter  is  a  frequent  source  of  error.  It  is  rare  that  the  two 
fixed  points  between  which  the  measurement  is  made  are  both  upon 
the  limb  or  the  bone  whose  length  is  in  question  ;  one  of  them  is  usually 
upon  the  trunk,  and  lies  at  a  certain  distance  from  the  centre  of  motion 
of  the  limb.  Consequently,  any  change  in  the  position  of  the  limb 
changes  the  distance  between  the  two  points  that  have  been  chosen. 
For  example,  in  measuring  the  length  of  the  lower  limb  the  points 
taken  are  the  anterior  superior  s])ine  of  the  ilium  and  the  tip  of  the 
malleolus ;  the  former  lies  several  inches  away  from  the  centre  of  the 
hip-joint,  and  when  the  limb  is  in  abduction  the  distance  between  the 
chosen  points  is  less  than  when  the  limb  is  parallel  to  the  long  axis  of 
the  body.  If  a  comparison  is  to  be  made  between  the  two  limbs,  it  is 
essential  that  their  position  with  reference  to  the  pelvis  should  be  the 
same,  and,  therefore,  care  must  be  taken  that  the  ankles  are  equidistant 
from  a  line  drawn  between  them  at  right  angles  to  and  from  the  centre 
of  another  connecting  the  two  anterior  iliac  spines. 

Similar  difficulties  and  uncertainties  exist  in  transverse  and  periph- 
eral measurements.  The  swelling  of  the  soft  parts  not  only  increases 
the  bulk  of  the  limb,  but  it  also  obscures  the  bony  prominences  and 
places  them  at  a  greater  distance  below  the  surface,  so  that  an  accurate 
measurement  of  the  distance  between  points  on  the  opposite  sides  of  a 
bone  is  practically  impossible.  For  this  and  for  rotatory  and  angular 
displacements  the  trained  eye,  aided  by  careful  and  minute  considera- 
tion and  palpation  of  the  anatomical  landmarks  and  comparison  M'ith 
the  opposite  limb,  is  the  best  guide. 

The  appearance  of  the  limb  will  be  still  further  modified  by  swell- 
ing due  to  extra vasated  blood  and  inflammatory  exudate,  and  some- 
times to  the  shortening  of  the  limb,  which  increases  its  transverse 
diameters. 

Ecchymosis  is  a  symptom  that  is  rarely  absent,  although  its  appear- 
ance may  be  delayed  for  several  days.  It  is  most  marked  and  most 
extensive  in  the  old.  The  blood  which  escapes  from  the  broken  bone 
and  the  adjoining  parts  makes  its  way  along  the  muscular  planes,  and 
first  appears  under  the  surface  at  some  distance  from  the  fracture.  Its 
appearance  at  certain  points  creates  a  strong  presumption  of  fracture 
— e.  g.,  beneath  the  malleoli  in  Pott's  fracture — and  the  same  interfer- 
ence is  measurably  justified  whenever  an  ecchymosis  appears  upon  a 
limb  that  has  not  been  directly  contused. 

Large  blebs,  the  serum  of  which  is  often  dark,  frequently  appear 
upon  the  leg  a  day  or  two  after  its  fracture;  less  frequently  uj)on 
other  limbs.     The  cause  of  their  ])roduction  is  not  known. 

In  fractures  communicating  with  joints  a  characteristic  deformity  is 
caused  by  the  filling  of  the  cavity  of  the  joint  with  blood  or  an  inflam- 
matory effusion,  the  situation  of  which  is  shown  by  its  limitation 
within  the  boundaries  of  the  articular  capsule. 

Abnormal  Mobility.     Mobility  appearing  after  injury  at  a  point  in  a 


EARLY  SYMPTOMS  AND  DIAGNOSIS.  55 

bone  where  it  did  not  previously  exist,  and  permitting  the  bone  to  be 
bent  at  an  angle,  or  a  portion  of  it  to  be  moved  while  the  other  por- 
tion remains  at  rest,  is  pathognomonic  of  fracture,  but  it  is  not  always 
present  or  recognizable,  for  the  fracture  may  be  incomplete  or  too  near 
a  joint,  or  one  of  the  fragments  may  be  too  small  or  too  deeply  placed 
to  be  grasped.  In  fracture  of  the  ribs,  sternum,  or  fibula  the  elasticity 
of  the  bone  may  deceive  if  not  taken  into  consideration,  or  raise  a 
doubt  if  it  is. 

The  manipulations  employed  for  the  detection  of  abnormal  mobility 
vary  with  the  seat  of  fracture  and  the  kind  of  mobility  which  is  sought 
to  be  produced.  In  fracture  of  the  shaft  of  a  long  bone  the  surgeon 
seeks  first  to  produce  an  angular  displacement  by  passing  his  hand 
under  the  limb  at  the  supposed  seat  of  fracture  and  gently  raising  it, 
or  by  grasping  the  two  extremities  of  the  bone  firmly  and  moving  the 
lower  one  slightly  from  side  to  side  while  the  upper  one  is  held  sta- 
tionary. Or  he  may  grasp  the  limb  with  both  hands  close  to  the 
fracture,  and  produce  transverse  displacement  by  moving  the  fragments 
bodily  in  opposite  directions.  In  fracture  of  the  shaft  of  the  fibula, 
radius,  or  ulna  lateral  mobility  may  be  detected  by  grasping  the  limb 
with  both  hands  above  and  below  the  fracture,  and  then  making  press- 
ure alternately  against  the  bone. 

In  fracture  of  the  upper  portion  of  the  shaft  of  the  femur  or  of  the 
neck  of  the  humerus  or  of  the  upper  end  of  the  tibia,  where  a  lateral 
or  angular  mobility  cannot  be  easily  recognized,  recourse  may  be  had 
to  slight  rotatory  movements  of  the  lower  portions  of  the  limb,  while 
the  upper  portion  is  so  held  that  its  bony  prominences  can  be  distinctly 
felt  by  the  fingers.  Abnormal  mobility  is  then  recognized  by  the 
failure  of  the  manipulation  to  transmit  the  rotatory  movements  to  the 
upper  fragment.  It  is  essential  that  the  communicated  movements 
should  be  slight,  for  otherwise  the  attachments  of  the  soft  parts  or  the 
interlocking  of  the  fragments  may  prevent  the  success  of  the  manoeuvre, 
which,  moreover,  for  obvious  reasons,  must  fail  in  partial  or  impacted 
fractures. 

In  fracture  of  either  condyle  of  the  femur  or  humerus,  or  in  frac- 
ture of  an  apophysis,  the  surgeon  must  try  to  grasp  the  fragment 
firmly  and  move  it  along  the  plane  of  fracture. 

It  is  sometimes  possible  to  give  a  fragment  a  tipping  or  see-saw 
motion  ;  thus,  by  pressing  the  tip  of  the  external  malleolus  inward, 
when  the  fibula  has  been  broken  just  above  the  ankle,  the  ui)per  end 
of  the  lower  fragment  may  sometimes  be  felt  to  move  outward.  In 
this  manipulation  the  sliding  of  the  skin  is  liable  to  be  mistaken  for 
movement  of  the  bone,  and  should  be  guarded  against  by  pressing  the 
fingers  toward  each  other  so  as  to  relax  the  skin  between  them. 

Crepitus.  This  is  the  sound  produced,  or  the  sensation  comnnmi- 
cated  to  the  hand  of  the  surgeon,  by  the  friction  of  the  fragments  of  a 
broken  bone  against  each  other.  It  is  as  pathognomonic  of  fracture 
as  is  abnormal  mobility,  and  these  two  signs  usually  coexist.  The 
sensation  is  not  the  same  in  all  cases;  it  may  be  the  shai'p  click  of  two 
hard  points  or  edges,  or  a  dull,  nniffled  contact,  or  the  crackling  and 
grating  of  multiple  fragments  and  broad  surfaces.     Some  of  its  forms 


56  FRACTURES. 

are  practically  identical  with  the  friction  sounds  obtained  by  the  move- 
ment of  joints  whose  surfaces  are  altered  by  disease,  and  although  it 
is  usual  to  speak  of  a  recognizable  diiference  in  the  quality  of  these  sen- 
sations, the  one  being  called  hard  or  rough,  the  other  soft  or  smooth, 
the  diagnosis  in  cases  of  doubt  must  depend  upon  circumstances  other 
than  this  difference. 

Crepitus  is  perceived  through  the  hand  rather  than  the  ear,  although 
sometimes  it  is  audible  to  bystanders  not  in  contact  with  the  patient. 
It  is  to  be  sought  by  the  same  methods  as  abnormal  mobility,  and  also 
in  the  ribs  and  flat  bones  by  placing  the  palm  of  the  hand  over  the 
supposed  seat  of  fracture  and  pressing  gently  in  various  directions. 
Direct  auscultation  is  sometimes  employed,  especially  in  fracture  of 
the  ribs  or  sternum. 

Crepitus  cannot  always  be  produced  when  there  is  a  fracture,  for 
its  production  is  conditioned  upon  the  contact  and,  in  a  measure,  the 
character,  of  the  broken  surfaces.  If  the  fragments  are  completely 
separated,  if  a  piece  of  muscle  or  fascia  is  interposed  between  them,  or 
if  they  have  become  covered  with  granulations,  their  movements  may 
not  cause  crepitus,  and  it  is  a  common  experience  that  the  manipula- 
tion which  produces  it  at  one  moment  fails  to  produce  it  at  the  next. 

Auscultatory  percussion,  the  stethoscope  being  moved  from  one  frag- 
ment to  the  other  while  percussion  is  made  upon  the  first,  will  some- 
times give  a  marked  change  in  the  sound  as  the  line  of  fracture  is 
crossed ;  but  it  is  rarely  significant,  except  in  cases  in  which  the  diag- 
nosis can  be  made  by  other  means. 

Conditions  giving  rise  to  sensations  that  may  be  mistaken  for  crep- 
itus are  :  Roughness  of  neighboring  joints,  inflammation  of  the  sheaths 
of  tendons  or  of  bursee,  and  the  crackling  of  coagulated  blood. 

Roentgen  Rays. — In  obscure  cases,  in  fractures  of  the  small  bones, 
and  to  determine  details  in  those  in  the  neighborhood  of  or  directly 
involving  joints,  the  x-rays  may  be  of  use  and  sometimes  of  great  value. 
Errors  of  interpretation  are,  however,  frequent.  It  must  be  borne  in 
mind  that  the  skiagram  is  the  reproduction  only  of  a  shadow,  and  that 
the  apparent  modeling  of  the  surface  of  the  bone  shown  in  it  is  the 
result  of  diiferences  of  opacity  and  is  often  misleading.  The  elements 
of  the  shadow  are  distorted  by  diiferences  in  the  relative  distances  of 
the  various  parts  from  the  plate  and  in  the  angle  of  the  rays,  and 
because  of  the  absence  of  perspective  these  distances  are  not  indicated. 
There  are  many  elements  of  error  in  a  skiagram,  many  possibilities  of 
misinterpretation,  which  must  be  controlled  by  experience  in  the  use  of 
the  rays  and  Ijy  digital  examination  of  the  part.  I  have  recently  seen 
a  case  clinically  diagnosticated  as  fracture  of  the  upper  third  of  the 
femur,  but  the  skiagram  of  which  was  thought  by  all  to  show  a  fracture 
at  the  base  of  the  neck.  The  autopsy  proved  the  correctness  of  the 
clinical  opinion.  The  skiagraphic  error  was  due  to  tilting  of  the  upper 
fragment.  An  additional  difficulty  is  caused  in  children  ]>y  the  per- 
meability of  cartilage  to  the  rays,  in  consequence  of  which  large  gaps 
corresponding  to  the  cartilaginous  epiphyses  appear  at  the  joints.  Ex- 
cept for  well-defined  changes  in  outline  of  a  single  bone  a  skiagram  can- 
not safely  be  taken  as  proof  of  all  it  seems  to  show,  but  needs  to  be  in- 
terpreted by  the  aid  of  clinical  findings  and  of  considerable  experience 


EARLY  SYMPTOMS  AND   DTAGNOSrS.  57 

in  its  use.  Particularly,  I  think,  do  we  need  to  be  upon  our  guard 
against  assuming  that  dark  lines  across  spongy  bone  always  indicate 
lines  of  fracture.  Stereoscopic  views  are,  of  course,  more  trustworthy 
than  single  ones,  but  they  are  not  often  available. 

Subjective  or  Rational  Symptoms. 

Loss  of  function  of  the  limb  or  part  involved  is  a  common  result  of 
fracture,  and  is  due  either  to  mechanical  causes,  such  as  the  breaking 
of  the  lever  through  which  the  muscles  act,  or  to  the  inhibitory  effect 
of  pain  or  the  fear  of  pain.  As  pain  due  to  other  causes  may  have 
the  same  effect,  and  as  the  loss  after  some  fractures,  even  of  the  main 
bone  of  a  limb,  may  be  at  first  slight,  the  presence  or  the  absence  of 
the  sym})tom  is  only  suggestive,  not  indicative,  of  the  presence  or 
absence  of  fracture.  In  most  cases  of  fracture  of  a  long  bone  the  limb 
is  practically  helpless,  but  from  time  to  time  we  meet  with  patients 
who  can  move  it  with  some  freedom  or  who  can  walk  with  a  broken 
ankle,  leg,  or  even  thigh. 

Pain,  spontaneous  or  on  pressure  upon,  or  movement  of,  the  broken 
bone,  is  a  constant  accompaniment  of  fracture.  Spontaneous  pain 
when  the  part  is  at  rest  is  usually  slight,  not  distinctly  limited  to  the 
seat  of  injury,  and  not  significant ;  but  localized  pain  on  pressure,  on 
movement  of  the  bone,  and  on  pressing  the  fragments  together  is  a 
valuable  symptom,  and  in  some  cases  the  most  positive  one  that  can  be 
obtained,  and  sufficient  in  itself  for  a  diagnosis.  It  is  to  be  sought  for 
by  pressure  with  the  tip  of  the  finger  along  the  line  of  the  bone,  by 
pressing  one  end  of  the  bone  toward  the  other,  or,  more  rarely,  by 
gentle  lateral  or  rotatory  movements  communicated  to  the  lower  por- 
tion of  the  limb  while  the  upper  is  fixed,  or  by  making  the  patient 
contract  a  muscle  attached  to  the  bone  while  its  movement  is  opposed, 
as  in  fracture  of  the  calcaneum  or  ulna.  It  is  of  great  diagnostic  impor- 
tance in  absence  of  the  positive  signs,  and  is  therefore  specially  valuable 
in  many  fractures  near  the  end  of  a  bone  and  in  those  of  the  metacarpals 
and  metatarsals  and  ribs,  and  its  absence  is  often  a  positive  means  of 
excluding   fracture. 

The  absence  of  pain  on  handling  an  important  fracture,  such  as  one 
of  the  leg  or  thigh,  deserves  attention  as  possibly  indicative  of  central 
nervous  disease  or  of  commencing  delirium  tremens. 

The  history,  with  reference  to  diagnosis,  includes  earlier  injuries  which 
may  have  modified  the  form  of  the  limb,  the  nature  of  the  accident, 
and  the  manner  in  which  the  force  was  applied,  the  interference  with 
function,  and  occasionally  the  snap  heard  at  the  time  and  the  distortion 
of  the  limb  observed,  A  knowledge  of  the  manner  in  which  the  vio- 
lence was  applied  is  sometimes  of  value  in  determining  obscure  points, 
and,  in  the  absence  of  positive  information,  indications  may  be  gathered 
from  the  position  of  contusions  or  of  stains  made  by  contact  with  the 
ground.  The  account  given  by  the  patient  must  always  be  received 
with  distrust,  because  of  his  preoccupation  by  other  circumstances  at 
the  moment  of  the  accident  and  of  the  tendency  to  substitute  inference 
for  observation. 

Such  are  the  facts  upon  which  the  diagnosis  is  made.     They  are  not 


58  FRACTURES. 

all  present  in  every  case,  aud  it  is  never  necessary  to  seek  for  them 
all ;  deformity,  abnormal  mobility,  aud  crepitus  are  alone  absolutely 
pathognomonic,  but  in  not  a  few  fractures  none  of  these  can  be  recog- 
nized by  manipulations  that  are  not  unduly  severe,  and  the  diagnosis 
must  be  made  upon  the  history  and  localized  pain.  It  is  important 
that  this  should  be  borne  in  mind,  for  many  a  fracture  has  been  over- 
looked because  crepitus  could  not  be  got.  The  character  of  the  injury 
is  sometimes  so  apparent  that  it  can  be  recognized  at  a  glance ;  in 
others  so  obscure  that  even  the  most  careful  and  experienced  observer 
may  remain  in  doubt.  In  most  cases  the  examination  should  be  made 
systematically  and  thoroughly,  beginning  with  the  history  and  follow- 
ing with  an  investigation  of  the  interference  with  function,  the  pain, 
the  deformity,  and  the  abnormal  mobility  and   crepitus  in  that  order. 

The  clothing  should  be  removed  from  the  injured  ])art,  and  in  doubt- 
fid  cases  also  from  the  opposite  limb.  After  having  noted  such  changes 
in  appearance  as  are  easily  recognizable,  the  surgeon  makes  gentle  press- 
ure with  his  fingers  along  the  limb  in  search  of  the  point  of  maximum 
tenderness  and  of  irregularity  of  outline  if  the  bone  is  subcutaneous, 
and  when  that  has  been  found  he  seeks  evidence  of  abnormal  mobility 
at  that  point  by  one  of  the  manipulations  above  mentioned.  If  the 
search  is  successful  the  diagnosis  is  made.  If  not,  or  if  the  injury  is 
at  a  point  where  abnormal  mobility  is  not  recognizable,  the  surgeon 
seeks  for  such  deformity  as  is  likely  to  exist  after  such  a  fracture  as  is 
suspected,  first  inquiring  whether  the  region  has  been  previously 
injured,  in  order  that  he  may  not  mistake  an  old  deformity  for  a  fresh 
one,  and  the  pain  of  a  sprain  for  that  of  a  fracture. 

If  neither  abnormal  mobility  nor  deformity  can  be  recognized  he 
tests  for  local  pain  by  pressure  in  the  long  axis  of  the  bone  or  by  the 
action  of  attached  muscles,  and  accepts  pain  thus  aroused  as  indicative 
of  the  presence  of  a  variety  of  fracture  which  may  not  give  the  signs 
that  are  lacking. 

If  doubt  still  remains  as  to  the  existence  of  a  fracture,  and  if  the 
search  for  signs  is  hampered  by  the  pain  that  the  necessary  manipula- 
tions cause,  or  if,  a  fracture  having  been  proved,  it  is  necessary  to 
determine  its  details,  he  employs  an  anaesthetic  after  having  made  his 
preparations  to  utilize  the  anaesthesia  for  the  reduction  of  displacements 
aud  the  application  of  a  dressing,  or  he  resorts  to  the  .r-rays. 

The  compound  character  of  a  fracture  is  easily  determined.  In 
fractures  by  indirect  violence  the  wound  in  the  skin,  close  to  the  seat 
of  fracture,  is  usually  small  and  bleeds  much  more  freely  than  a  simple 
wound  of  the  skin  would ;  in  fractures  by  direct  violence  the  tegu- 
mentary  wound  is  usually  large  and  I'agged,  and  the  broken  ends  of 
the  bones  can  be  seen  or  felt  through  it.  It  is  not  necessary  positively 
to  determine  the  existence  of  direct  communication  between  the  frac- 
ture and  the  external  wound;  the  coexistence  of  the  two  is  sufficient 
to  make  imperative  the  employment  of  every  precaution  against  infec- 
tion that  would  be  called  for  if  such  communication  were  known  to 
exist.  If  the  wound  is  explored  at  all,  it  should  be  done  only  as  a 
part  of  the  treatment,  and  with  strict  asepsis,  not  merely  as  a  diagnos- 
tic measure. 


CHAPTER  V. 

THE  REPAIR  OF   FRACTURES  AND  THE  CLINICAL  COURSE. 
Anatomo-pathological  Processes. 

The  Callus.  Bone  is  one  of  those  tissues  whose  cicatrices  are  com- 
posed of  a  sabstance  closely  resembling,  or  identical  with,  the  original 
tissue.  The  process  of  repair  after  fracture  is  fundamentally  the  same 
as  that  after  other  forms  of  injury,  and  its  histological  phenomena, 
like  those  of  repair  of  other  tissues,  are  those  of  normal  growth  and 
exaggerated  nutrition.  It  begins  with  the  enlargement  and  multipli- 
cation of  the  cells  of  the  periosteum,  marrow,  Haversian  canals,  and 
lacunae;  this  multiplication  produces  a  mass  of  granulations  which  fill 
the  gap  between  the  fragments  and  are  transformed  into  bone,  some- 
times directly,  sometimes  after  having  passed  through  a  cartilaginous 
stage.  This  mass  of  new  bone,  at  first  spongy  in  its  structure — that 
is,  composed  of  irregular  lamellse  or  plates  circumscribing  relatively 
large  lacunae  filled  with  bloodvessels  and  medullary  elements — becomes 
firmer  and  more  compact  in  some  portions  by  increase  in  thickness  of 
the  lamellse  and  consequent  reduction  in  size  of  the  lacunae — the  pro- 
cess known  as  "condensing  o.steitis,"  and  observed  constantly  in  the 
foetus  as  well  as  in  many  pathological  conditions — and  becomes  thinner 
and  weaker  in  other  portions  until  it  finally  disappears  by  tlie  con- 
verse process,  diminution  of  the  lamellae  through  their  absorption  by 
the  medullary  elements  of  the  lacunae,  "  rarefying  osteitis,"  anotlier 
stage  of  productive  or  simple  osteitis  and  also  found  in  the  normal 
development  of  bone  and  in  pathological  conditions.  The  variations 
depend  upon  differences  in  the  degree  of  the  injury  or  in  the  position 
of  the  fragments,  which  require  disproportionate  amounts  of  work  to 
be  done  by  the  different  parts.  The  details  of  the  process  will  appear 
upon  examination  of  the  manner  in  which  it  is  carried  on  after  simple 
fracture  of  the  shaft  of  a  long  bone,  an  example  which  has  tiie  advan- 
tage of  illustrating  the  behavior  of  all  the  different  elements  and  of 
being  both  more  complete  and  more  open  to  experimental  study  than 
fractures  of  short  bones  or  of  the  spongy  extremities  of  long  ones. 

When  a  fracture  takes  place  the  cylindrical  shell  is  l)rok('n  along  an 
irregular  line  and  probably  always  with  the  ])roduction  of  splinters  of 
greater  or  less  size.  The  periosteum  is  usually  torn,  but  the  extent  of 
its  rupture  has  probably  been  largely  overestimated  even  when  there 
is  much  displacement  of  the  fragments.  Oilier'  was  the  first  to  call 
especial  attention  to  the  preservation  of  its  contiiniity  at  some  part  of 
the  periphery  of  the  bone  and  to  the  fact  that  when  a  lateral  or  h)ngi- 
tudinal  displacement  has  occurred  the  membrane  is  stripped  partly 
'  Oilier:  Traite  de  la  Regeneration  des  Os. 
5  ( 50  ) 


60  FRACTURES. 

off  one  fragment,  but  without  having  its  continuity  broken,  and  thus 
forms  a  band  uniting  the  two  fragments.  To  this  band  he  gave  the 
name  of  "  periosteal  bridge."  Other  portions,  also,  which  do  not 
preserve  their  continuity  with  the  rest,  are  doubtless  stripped  off  the 
fragments,  as  can  be  seen  in  compound  fractures,  and  as  they  are 
structurally  continuous  with  the  overlying  soft  parts  they  probably 
come  quite  accurately  into  place  when  the  displacement  is  corrected, 
and  thus  form  a  fairly  complete  tubular  sheath  connecting  the  ends 
of  the  fragments  and  all  splinters  except  those  which  are  entirely 
loose,  guiding  and  limiting  the  formation  of  the  new  tissue  that  is  to 
establish  the  ultimate  union.  When  this  sheath  is  not  complete, 
because  of  persisting  displacement,  the  existence  of  the  periosteal 
bridge  is  of  extreme  importance,  because  it  maintains  the  connection 
between  the  fragments  by  means  of  a  tissue  whose  activitv  in  the  pro- 
duction of  bone  is  marked.  The  position  and  form  of  the  callus  in 
specimens  of  union  with  displacement  indicate  clearly  the  position  and 
agency  of  the  bridge,  and  Plate  II.  shows  the  ossification  on  the  inner 
surface  of  the  bridge,  but  not  complete  throughout  the  interval  between 
it  and  the  surface  of  the  bone. 

At  the  same  time  blood  is  poured  out  from  the  torn  vessels  of  the 
bone  into  the  gap  between  the  fragments  and  from  the  vessels  of  the 
soft  parts  into  the  interstices  among  the  muscles.  This  blood  is  grad- 
ually absorbed  during  the  first  few  days  following  the  receipt  of  the 
injury,  and  at  the  same  time  the  effects  of  the  traumatism  are  mani- 
fested in  the  inflammatory  oedema  of  the  limb  and  the  infiltration  of 
a  thick  viscid  liquid  into  the  soft  tissues  immediately  adjoining  the 
seat  of  the  fracture,  the  beginning  of  the  firm  ovoid  mass  which  can 
always  be  felt  at  this  point.  The  periosteum  becomes  much  thicker, 
softer,  and  more  vascular ;  a  thin  layer  of  gelatinous  or  viscid  liquid 
is  found  between  it  and  the  bone  for  a  distance  of  a  few  lines  from 
the  edge  of  the  fracture  or  from  the  point  to  which  the  membrane  has 
been  stripped  up,  and  at  the  more  distant  limit  of  this  layer  the  sur- 
face of  the  bone  promptly  become  roughened  by  the  formation  of 
patches  of  new  bone.  The  portions  of  the  periosteum  which  have 
been  stripped  off,  those  which  form  complete  or  incomplete  bridges, 
and  the  lacerated  tissues  which  form  the  wall  of  the  cavity  in  which 
the  ends  of  the  bone  lie,  granulate  and  pour  out  an  exudate  to  mingle 
with  the  remaining  blood. 

The  marrow  shares  in  this  production  of  grantilations,  and  the  cells 
of  the  connective  tissue  external  to  the  periosteum  share  for  a  greater 
or  less  distance  in  the  irritation,  and  by  their  proliferation  bind  to- 
gether all  the  adjoining  parts  in  one  firm,  compact  mass.  The  com- 
pact layer  of  bone,  the  cylindrical  shellof  the  shaft,  feels  the  same 
influence  and  reacts  in  the  same  manner,  but  much  more  slowly  in 
consequence  of  the  scantiness  of  its  cellular  elements.  Its  outer  and 
broken  surfaces  soon  show  pink  points  which  enlarge  and  send  out 
granulations  to  join  those  already  produced  by  the  periosteum  and 
marrow,  and  thus  there  is  formed  between  the  separated  fragments  a 
bond  of  union  which  is  actually  continuous,  almost  from  the  beginning, 
with  all  their  constituent  parts.    The  size  and  character  of  this  bond  vary 


THE  REPAIR   OF  FRACTURES  AND   THE  CLINICAL  COURSE.  61 


Fig.  30. 


with  the  degree  of  displacement ;  if  the  fragments  remain  nearly 
in  their  original  relations  to  each  other,  the  bond  is  short  and  sym- 
metrical, the  granulations  springing  from  the  marrow  meet  and  unite 
in  the  centre  of  the  gap,  while  the  thickened  periosteum  passes 
from  one  fragment  directly  to  the  other,  remaining  adherent  to  them 
or  separated  only  by  a  layer  of  effused  blood.  If  lateral  displace- 
ment occurs  and  persists,  the  bond  passes  obliquely  from  the  outer 
surface  of  one  fragment  to  that  of  the  other,  and  is  much  more 
complete  at  some  points  of  the  periphery  than  at  others.  Thus,  in 
Fig.  30,  which  represents  the  condition  on  the  seventh  day,  the  firmest 
union  is  by  the  cartilaginous  band  crossing  the 
angle  at  6  and  formed  apparently  by  the  thick- 
ening of  a  periosteal  bridge.  On  the  opposite 
side  of  the  lower  fragment  the  beginning  of 
an  incomplete  band  of  similar  structure  is  seen. 

The  formative  action  thus  begun  is  rapidly 
carried  on,  and  principally  by  the  periosteum 
and  marrow.  When  the  fragments  are  kept 
end  to  end  an  ovoid  mass  of  tissue,  having  the 
consistency  of  jelly  and  a  pearly  white  appear- 
ance, and  continuous  above  and  below  with  the 
periosteum,  envelops  them,  the  so-called  "  pro- 
visional "  or  "  ensheathing  "  callus.  This  mass 
is  formed  not  solely  by  granulations  springing 
from  the  under  side  of  the  periosteum,  but  also 
by  the  thickening  of  that  membrane  and  of  the 
connective  tissue  on  the  outer  side,  including 
that  which  surrounds  the  adjoining  muscular 
bundles,  and  according  to  Cornil  and  Coudray,^ 
even  the  cells  of  the  sarcolemma.  Composed 
at  first  of  embryonal  elements,  it  soon  becomes 
cartilaginous  in  the  portions  formed  by  the  per- 
iosteum ;  then  lime  salts  are  deposited  at  dif- 
ferent points  within  it,  and  finally  it  is  transformed  into  bone. 

The  granulations  that  spring  from  the  marrow  ossify  without  passing 
through  the  cartilaginous  stage,  and  the  process  here  apparently  begins 
at  the  fine  lamellse  which  lie  upon  the  inner  side  of  the  compact  shell. 
The  new  lamellte  extend  across  the  canal,  soon  occluding  it  entirely, 
and  also  out  into  the  interval  to  meet  those  coming  from  the  other 
fragment.     Thus  is  formed  the  internal  or  medullary  i)lug. 

The  granulations  occupying  the  annular  interval  between  the  cortical 
layers  of  the  two  fragments  (when  the  reduction  is  complete)  apparently 
come  mainly  from  the  periosteum  and  pass  through  a  cartilaginous 
stage  before  becoming  bone,  as  do  the  others  that  have  the  same  origin. 
They  unite  promptly  with  those  of  the  medullary  plug  and  ultimately 
(sometimes  after  a  long  delay)  with  the  cortical  layer.  It  was  to  this 
part  of  the  callus  that  Dupuytren  gave  the  name  of  "  definitive  callus." 
The  cause  of  the  delay  in  union  with  the  cortical  layer  lies  in  the  slow- 
ness with  which  the  latter  forms  the  granulations  necessary  to  unite 
with  the  others,  and  doubtless  to  the  occasional  long  persistence  of  a 
1  Cornil  and  Coudray,  Revue  de  Chir.,  24th  year,  No.  7. 


Tibia  of  rabbit.  Seventh 
day :  a,  blood  ;  b,  cartilag- 
inous   callus ;    c,    muscles. 

(GURLT.) 


62  FRACTURES. 

necrotic  scale  of  bone  on  its  broken  surface,  whicli  has  to  be  slowly 
penetrated  and  absorbed  by  the  granulations.  The  cellular  elements 
of  the  cortex,  which  have  to  do  the  work  of  enlarging  the  Haversian 
canals  and  forming  the  granulations,  are  scanty,  and  those  immediately 
adjoining  the  broken  surface  cannot  share  in  the  work  because  their 
blood-supply  is  cut  off  by  the  clotting  of  the  blood  in  the  torn  capil- 
laries. The  cells  situated  a  little  more  deeply  have  to  carry  on  the 
work  and  slowly  break  through  the  intermediate  necrotic  scale  before 
they  can  meet  and  unite  with  the  other  granulations  that  have  spread 
into  the  interval  from  without  and  within.  This  process  in  the  com- 
pact tissue  is  the  usual  rarefying  osteitis,  characterized  by  an  enlarge- 
ment of  the  Haversian  canals  and  a  corresponding  loss  of  the  bone 
tissue,  a  change,  in  short,  which  transforms  the  cortex  for  a  certain 
distance  into  spongy  tissue  like  that  of  the  ossifying  callus.  Ulti- 
mately the  rarefaction  ceases  and  a  "  productive  "  or  "  condensing  '' 
osteitis  follows,  by  which  the  lamellae  are  thickened  and  the  interme- 
diate spaces  and  canals  contracted  until  the  former  proportions  between 
them  are  measurably  restored.  Occasionally  the  ossification  spreads 
into  ligaments  and  tendons  attached  to  the  bone  close  by  the  fracture. 

While  the  callus  is  thus  forming  and  ossifying,  the  irritation  in  the 
adjoining  soft  parts  subsides,  and  they  regain  their  original  condition 
and  functions  more  or  less  completely.  Occasionally  the  associated 
injuries  of  muscles  or  tendons  or  the  sheaths  of  the  latter  lead  to  per- 
manent disabling  adhesions. 

After  the  ossification  of  the  callus  has  been  completed  the  excess  on 
its  exterior  and  even  projecting  portions  of  fragments  slowly  disap- 
pear, and  in  cases  in  which  the  reduction  of  the  displacements  has 
been  exact  this  disappearance  of  the  exterior  callus  may  go  so  far  as 
to  leave  little  or  no  trace  on  the  surface  of  its  previous  existence.  In 
like  manner  the  central  plug  diminishes  and  the  medullary  canal  may 
be  restored. 

Fragments  of  the  cortical  layer  broken  off  at  the  time  of  the  injury 
may  remain  attached  to  the  periosteum,  preserve  their  vitality,  share 
in  the  same  processes,  and  form  a  part,  often  an  important  one,  of  the 
callus.  There  is  reason  to  believe  also  that  even  after  they  have  been 
entirely  detached  they  may  form  new  connections  with  the  s()ft  parts 
and  granulations,  and  preserve  (or  renew)  their  life.  Such  fragments 
have  been  found  embedded  so  deeply  in  a  callus  that  no  other  expla- 
nation than  that  of  complete  detachment  can  well  be  accepted.  How- 
ship  describes  and  figures  one,  and  Gurlt  another  and  remarkable  one 
(Fig.  31).  The  possibility  of  this  preservation  has  also  been  estab- 
lished by  experiment  upon  animals.  Portions  of  the  shaft  have  been 
chiselled  off,  separated  entirely  from  the  soft  parts,  and  replaced  in 
contact  with  the  bone ;  examination  after  the  lapse  of  some  weeks 
showed  re-establishment  of  vascular  connection. 

It  is  also  known  that  fragments  may  long  remain  without  vascular 
connection  embedded  in  a  callus  as  well-tolerated  foreign  bodies.  After 
the  lapse  of  months,  or  even  years,  and  from  unknown  causes,  they 
may  cause  irritation  ;  an  abscess  forms,  the  bone  softens  about  them, 
and  either  they  are  cast  out  spontaneously  or  they  remain,  provoking 
an  interminable  suppuration,  until  removed. 


THE  REPAIR   OF  FRACTURES  AND   THE  CLINICAL   COURSE.  63 


Fig.  31. 


It  occasionally  happens  that  tlie  callus  does  not  ossify,  and  in  some 
very  exceptional  cases  the  bone  is  entirely  absorbed  for  a  considerable 
distance  on  each  side  of  the  seat  of  fracture.  The  causes  are  not  fully 
understood.  The  difiPerence  in  the  process  consists  in  an  entire  or 
partial  absence  of  productive  osteitis  and  in  an 
excess  of  the  rarefying  osteitis.  Tiie  latter,  I 
am  convinced,  is  favored  by  the  presence  of  a 
metallic  suture  in  the  bone  at  the  fracture. 

When  the  fracture  is  compound,  and  remains 
so,  the  details  of  the  reparative  process  are  dif- 
ferent to  this  extent:  that  the  callus  does  not 
pass  through  the  preliminary  cartilaginous  stage 
at  any  point  where  suppuration  has  occurred. 
The  formation  of  the  medullary  plug  is  not 
affected,  the  granulations  there  being  transformed 
directly  into  bone  as  they  are  in  simple  fractures; 
the  difference  is  in  the  external  or  ensheathing 
callus.  The  reason  of  this  difference,  as  shown 
by  experiment/  lies  in  the  destruction  of  the 
detached  surface  of  the  periosteum  by  the  sup- 
pm*ative  process,  in  the  destruction,  that  is,  of 
the  only  tissue  whose  granulations  pass  through 
the  cartilaginous  stage  in  forming  the  callus. 
The  process  is  slower  than  after  a  sim])le  frac- 
ture because  the  suppuration  of  the  wound  delays 
or  prevents  the  formation  of  much  of  the  exter- 
nal callus  and  throws  most  of  the  labor  upon  the 
bone  itself,  which,  as  has  been  shown,  is  the  least 
able  to  do  it.     It  is  easy  to  watch  the  process. 

The  ends  of  the  bone  are  seen_  lying  bare  and  p^,^^,^^^  ^^  ^^^  ^^^^^  ^^ 
white  in  the  wound;  a  mass  of  pink  granulations  the  femur  and  of  the  shaft. 
forms  at  the  limit  of  the  denudation  and  ad-  Aspiinters  inches  long  and 
vances    slowly    across    the    bared     surface;    the   "^ariy  i  inch  wide  com- 

,        ,  _    •'  •        f  •  •  1  posed  of  the  cortical  layer, 

broken  surface  remains  for  a  time  quiescent,  then   has  been  turned  completely 
granulations    spring    from    it,   beginning    at   the  about  its  long  axis  and  be- 
points  nearest  the  medullary  canal  and  spreading 
slowly  toward  the  outer  edge  ;  the  wound  gradu- 
ally fills  up  with  these  granulations,  the  bone  is 
covered  in,  and  cicatrization  follows. 

n  less  fortunate  cases  a  portion  of  tlie  bared   England,  No.  454.) 
bone  dies  and  is  cast  off  by  the  formation  of  a 

line  of  demarcation  which  can  sometimes  be  seen  at  the  edge  of  the 
granulations,  but  which  more  commonly  is  hidden  by  them.  It  must 
not  be  thought  that  all  the  bare  white  bone  seen  in  such  a  wound  is 
dead,  even  after  it  has  remained  unchanged  in  appearance  for  several 
weeks.  Its  surface  may,  indeed,  be  dead,  but  the  interior  is  oi\on 
alive  and  able  to  cast  off  the  dead  su])erficial  scale  without  aid.  Tlie 
grainilations  which  form  between  the  living  and  the  dead  ])arts  seem 
1  Eigal  and  Vignal :  Comptes-Eendiis  de  rAcademie  des  Sciences,  1880,  vol.  xc.  p.  1218. 


come  united,  with  its  orig- 
inal periosteal  surface  in 
contact  with  the  other  frag- 
ments. (Figured  by  Guiu.t 
from  the  Museum  of  the 
Royal  College  of  Surgeons, 


64  FRACTURES. 

sometimes  to  dissolve  and  absorb  the  latter  if  they  are  small  and  thin, 
or,  if  not,  slowly  to  bear  them  to  the  surface  and  cast  them  out. 

The  callus  thus  formed  is  larger  and  more  irregular  than  after 
simple  fracture ;  it  remains  tender  and  sensitive  for  a  long  time,  and 
is  covered  by  an  adherent  scar  at  the  seat  of  the  wound.  Fragments 
formed  at  the  time  of  the  accident  and  remaining  attached  to  the  peri- 
osteum usually  preserve  their  vitality ;  if  not,  they  become  detached 
after  a  time  and  are  found  loose  in  the  wound,  or  become  shut  in  by 
the  callus  and  prolong  the  suppuration  indefinitely.  In  this  latter  case 
the  constant  irritation  due  to  the  presence  of  the  foreign  body,  the  exist- 
ence of  sinuses,  and  the  burrowing  of  the  pus  interfere  with  the  evolu- 
tion of  the  callus.  Instead  of  undergoing  a  gradual  and  uniform 
diminution  and  condensation,  it  becomes  eburnated  at  some  ])oints  and 
entirely  absorbed  at  others,  irregular  prominences  appear  on  its  surface 
or  follow  the  lines  of  attached  tendons  and  fasciae,  and  its  interior  is 
occupied  by  cavities  of  various  sizes  usually  suppurating  and  in  com- 
munication with  the  exterior. 

In  the  spongy  "bones  and  the  spongy  ends  of  the  long  bones  less  of 
the  work  of  repair  is  done  by  the  periosteum  and  more  by  the  bone 
itself,  for  the  periosteum  is  so  interrupted  by  attached  tendons  and 
ligaments  that  it  is  less  freely  stripped  up,  and  the  bone  surfaces  are 
broadly  in  contact  and,  being  spongy,  are  ready  at  once  to  form  gran- 
ulations without  preliminary  rarefaction. 

In  fractures  involving  joint-surfaces  the  absence  of  periosteum  and 
other  soft  tissues  on  the  articular  surface  prevents  the  formation  of  an 
external  callus  on  that  side,  and  union  takes  place  by  granulations 
arising  directly  from  the  fractured  surfaces  and  by  an  external  callus 
at  the  extra-articular  parts  of  the  fracture.  The  line  of  the  fracture 
on  the  articular  surface  is  marked  by  the  absence  of  cartilage  over  it, 
and  usuallv  bv  a  groove.  The  fracture  of  the  cartilage  does  not  heal 
by  the  formation  of  new  cartilage  ;  usually  the  callus  is  covered  at  this 
point  by  a  firm  white  layer  of  fibrous  tissue,  but  sometimes  the  bone 
is  bare.  In  exceptional  cases  the  callus  is  exuberant  and  grows  out 
beyond  the  level  of  the  cartilage,  forming  an  irregular  mass  in  place 
of  the  usual  groove. 

Fracture  of  cartilage  (costal  cartilage,  larynx,  etc.)  is  repaired  partly 
by  a  fibrous,  rarely  a  cartilaginous,  band  between  the  fragments,  and 
partly  by  a  bony  peripheral  callus.     (See  Chapter  XYI.) 

Exuberance  c_"  the  callus,  both  external  and  intermediate,  is  a  fre- 
quent cause  of  diminution  of  the  functions  of  the  joint  by  destroying 
the  normal  relations  of  the  articular  surfaces,  h\  filling  up  normal 
depressions,  and  by  creating  abnormal  prominences.  These  results  are 
usually  beyond  the  control  of  the  surgeon,  and  the  latter  are  most 
common  in  the  young,  whose  power  of  producing  bone  is  greatest. 
Occasionally  the  productive  process  excited  by  the  fracture  extends  far 
beyond  the  limits  of  the  latter,  and  not  only  may  the  joint  itself  be 
obliterated  by  fusion  of  the  bones  which  constitute  it,  Init  the  process 
may  also  spread  to  and  produce  the  same  result  in  neighboring  joints 
as  in  the  case  represented  in  Fig.  32. 

Bones  which  lie  parallel  and  close  to  each  otlier,  as  those  of  the  fore- 


THE  REPAIR   OF  FRACTURES  AND   THE  CLINICAL   COURSE.  65 


arm  and  leg  and  the  ribs,  may  become  united  by  an  exuberant  callus 
when  either  one  or  both  are  broken.  This  consolidation  is  most  likely 
to  occur  when  both  bones  are  broken  at  the  same  level,  and  Mhen  dis- 
placement of  one  or  more  of  the  fragments  diminishes  the  normal  inter- 
val between  them.  The  mass  of  granulations  developed  about  one 
fracture  becomes  continuous  with  that  developed  about  the  other,  and 
ossification  follows.  The  presence  of  an  interosseous  membrane  favors 
this  result,  for  this  tissue  has  the  same  tendency  to  ossify  that  is  shown 


Fig.  32. 


Fig.  33. 


Bony  anchylosis  of  the  foot  and  ankle 
after  fracture  of  the  leg.    (Gurlt.) 


Absorption  of  the  neck  of  the  femur  after  fracture. 


by  other  wliite  fibrous  tissue  in  the  presence  of  a  productive  osteitis.  The 
effect  of  this  consolidation  is,  of  course,  to  prevent  independent  motion 
of  the  two  bones,  and  while  of  no  importance  in  the  log  and  of  little,  if 
any,  in  the  ribs,  it  produces  a  very  serious  disability  in  the  forearm  by 
abolishing  pronation  and  supination.  It  occasionally  happens,  M'hen  two 
bones  are  broken  at  the  same  level,  that  the  calluses  grow  into  contact 
with  each  other  but  do  not  unite.  Their  adjoining  surfaces  are  smooth 
and  together  form  a  sort  of  lateral  joint  which  may  allow  movement 
of  one  upon  the  other. 

When  the  line  of  fracture  follows  that  of  a  still  existing  epiphyseal 
cartilage,  either  wholly  or  in  part,  and  the  fragments  are  not  disphioed, 
union  apparently  takes  place  as  readily  as  after  simple  fracture,  but 
nothing  positive  is  known  of  the  details  of  the  process.  The  injury 
does  not  nece.ssarily  interfere  Avith  the  subsequent  growtii  of  the  bone  ; 
the  layer  of  cartilage  may  remain  unossified  and  perform  its  functions 


66  FRACTURES. 

as  before ;  but  it  is  known  from  the  results  of  experiments  upon  ani- 
mals, and  from  cases  of  inflammatory  disease  and  from  some  of  trau- 
matic separation  without  displacement,  that  the  effect  of  irritation  of 
the  epiphyseal  cartilage  is  sometimes  to  hasten  its  ossification,  and  thus 
arrest  the  growth  of  the  limb.  This  last  result  must  certainly  be  pro- 
duced when  the  epiphysis  is  dislocated  by  the  fracture  and  is  not 
restored  to  its  place. 

Finally,  failure  of  union  after  fracture  may  be  due  to  arrest  of  the 
reparative  process  in  the  granulation  stage,  ossification  not  taking 
place  and  the  bond  between  the  fragments  remaining  fibrous,  or  to  the 
wide  separation  of  the  fragments,  or  to  the  interposition  of  a  bundle 
of  muscular  tissue,  or  to  the  insufficiency  of  the  blood-supply  of  one 
of  the  fragments.     This  condition,  especially  as  seen  after  fracture  of 

Fig.  34. 


Fracture  of  the  olecranon  :  fibrous  union.    (Malgaigne.) 

the  shaft  of  a  long  bone,  is  considered  in  detail  in  Chapter  VIII., 
Pseudarthrosis.  Examples  at  other  points  than  the  shaft  are  furnished 
especially  by  the  patella  and  olecranon  (direct  longitudinal  separation), 
and  by  some  fractures  of  the  neck  of  the  femur  where  the  cause  lies 
in  an  excess  of  the  rarefying  process,  by  which  the  neck  is  destroyed, 
or  in  the  cutting  off  of  the  blood-supply  by  complete  rupture  of  the 
periosteum  of  the  neck  which  carries  vessels  to  the  head. 

Clinical  Course, 

This  varies  with  the  position  and  character  of  the  fracture  and  espe- 
cially with  the  complications  arising  from  the  peculiarties  of  the 
fracture  and  the  health  and  age  of  the  patient.  Ordinarily,  in  simple 
cases,  after  the  primary  reaction  of  the  injury  has  subsided  and  an 
appropriate  treatment  has  been  established,  the  patient  goes  on  to 
recovery  without  pain,  fever,  or  other  disturbance  of  his  general 
health,  and  incommoded  only  by  the  disability  of  the  limb  and  the 
confinement  to  which  he  is  subjected.  But  in  the  alcoholic  this  tran- 
quil course  may  be  promptly  interrupted  by  the  onset  of  a  pneumonia 
or  an  attack  of  delirium  tremens;  and  in  the  old,  confined  to  bed  by  a 
broken  thigh  or  leg,  the  primary  shock  may  be  sufficient  to  cause 
death  in  the  first  few  days,  or  the  general  health  may  begin  to  suffer 
about  the  third  week,  and  death  follow  after  a  short  interval  marked 
by  symptoms  of  hypostatic  pneumonia  or  mild  delirium  and  gradual 
failing  of  the  strength.     And   very,  very  rarely,  even  in  simple  cases 


THE  REPAIR   OF  FRACTURES  AND   THE  CLINICAL   COURSE.  G7 

and  without  the  slightest  warning,  death  may  come  suddenly  in  tlie  first 
few  days  by  fat  embolism  of  the  lungs,  or  at  a  later  period  bv  a  car- 
diac pulmonary  embolus  detached  from  a  thrombus  in  some  large  vein. 

For  tiie  first  day  or  two  the  patient  may  suffer  pain  at  and  near  the 
fracture,  augmented  by  muscular  twitchings,  and  considerable  discom- 
fort from  the  weight  and  tension  of  the  swollen  limb ;  and  if  the  bone 
is  a  large  one  (thigh,  leg,  arm)  and  the  fright  and  emotion  at  the  time 
of  the  accident  extreme,  the  symptoms  of  shock   may  be  well  marked. 

The  temperature  usually  shows  a  rise  of  from  one  to  two  degrees 
Fahrenheit,  "aseptic"  fever,  which  promptly  diminishes,  antl  disap- 
pears within  a  few  days.  At  the  same  time  the  urine  ma}'  contain  a 
small  amount  of  albumin  and  free  fat  and  hyaline  casts  enclosing 
brown  granules.  The  fat,  which  is  sometimes  sufficient  to  form  a  dis- 
tinct layer  on  the  surface  after  standing,  is  thought  to  come  from  the 
crushed  marrow  of  the  bone,  and  the  variations  in  its  quality  and  the 
time  of  appearance  to  depend  upon  its  temporary  arrest  in  the  pulmo- 
nary capillaries  (fat  embolism,  q.  v.).  The  brown  casts  are  sometimes 
very  numerous,  but  more  often  are  wholly  lacking. 

Bernadi^  has  shown  that  a  leucocytosis,  more  marked  in  the  young 
than  in  adults,  appears  in  a  day  or  two  and  reaches  its  maximum  in 
ten  or  fifteen  days.  The  eosiuophiles  first  diminish,  then  increase 
rapidly  in  cases  that  do  well ;  their  increasing  diminution  is  an  unfavor- 
able sign  and  suggests  grave  complications. 

The  limb  swells,  partly  because  of  extravasated  blood  and  shorten- 
ing, but  mainly  by  oedema;  the  swelling  reaches  its  maximum  on  the 
second  or  third  day  and  then  slowly  subsides.  The  skin  of  the  involved 
region  shows  a  yellowish  tinge,  the  result  of  staining  with  the  coloring 
matter  of  the  extravasated  blood,  and  ecchymoses  appear  at  points 
below  and  sometimes  above  the  fracture.  Larger  or  smaller  blebs 
appear,  especially  on  the  legs,  by  the  second  or  third  day,  and  may 
interfere  with  the  early  application  of  a  fixed  dressing. 

As  the  swelling  subsides  a  firm  ovoid  mass  becomes  recdgnizable, 
extending  above  and  below  the  fracture,  and  the  sensitiveness  on 
pressure  diminishes;  this  mass  diminishes  in  size  and  increases  in  firm- 
ness as  time  passes,  the  abnormal  mobility  diminishes,  and  finally, 
after  a  length  of  time  whicli  varies  greatly  in  different  cases,  ceases, 
and  union  is  then  effected,  although  not  so  firm  as  it  will  ultimately 
become  after  ossification  shall  have  been  completed.  A  small,  hard 
mass  can  still  be  felt  at  the  seat  of  fracture  which  will  slowly  diminish 
for  months,  perhaps  for  years. 

Other  things  being  equal,  and  bone  for  bone,  less  time  is  required 
to  complete  repair  in  children  tlian  in  adults ;  and  fractures  heal  as 
ra])idly  in  one  sex  as  in  the  other,  and  in  the  old  as  ra])idly  as  in  tlie 
middle-aged.  As  a  general  rule,  too,  the  larger  the  bone  the  longer 
the  time  requii'ed,  and  fractures  of  the  shaft  require  more  time  than 
those  of  the  spongy  ends,  and  those  with  uncorrected  displacement 
more  than  those  in  which  the  normal  relations  have  been  maintained 
or  restored.     The  average  for  fractures  of  the  shaft  of  the  long  bones 

1  Bernadi :  Alcune  modificazioni  nel  sangue  del  fratturati.  Tisa,  1907.  Abst.  in 
Zfiiti-alblatt  fiir  Chir.  1908,  p.  1424. 


68  FBACTVEES. 

in  adults  varies  from  four  weeks  for  the  clavicle  or  forearm  to  eight  or 
nine  weeks  for  the  thigh. 

But  it  must  be  remembered  that  even  after  union  has  apparently 
become  firm,  displacement,  usually  angular,  may  slowly  be  produced  by 
the  repeated  action  of  moderate  force,  such  as  the  weight  of  the  body 
in  walking  after  fracture  of  the  thigh  or  leg,  and  specially  after  frac- 
ture of  the  neck  of  the  femur. 

But  with  the  union  of  the  fracture  the  recovery  of  the  patient,  espe- 
cially after  fractures  of  the  limbs,  is  not  yet  complete.  The  circula- 
tion of  the  part,  the  skin,  the  muscles,  and  the  neio:hboring  joints  have 
yet  to  recover  from  the  disabilities  imposed  upon  them  by  the  primary 
injury  or  by  the  prolonged  disuse  of  the  limb.  The  skin  is  harsh  and 
dry;  the  limb  swells  and  shows  venous  congestion  when  used,  and 
especially  when  dependent,  presumably  because  of  plugging  of  the 
veins  and  possibly  because  of  rupture  of  lymphatic  channels  ;  the 
joints  are  swollen,  stiff,  and  sensitive.  As  a  rule,  all  these  features 
disappear  under  use,  and  more  rapidly  in  the  young  than  in  the  old, 
but  occasionally  some  of  them  persist  for  a  long  time. 

The  course  of  the  case,  as  thus  sketched,  may  be  greatly  modified  by 
exceptional  severity  of  the  injury,  by  associated  lesions,  or  by  a  wound 
or  contusion  which  makes  the  fracture  compound  either  immediately 
or  after  the  lapse  of  a  few  days.  In  the  severe  cases,  with  more  splin- 
tering of  the  bone  and  laceration  of  the  soft  parts,  the  pain,  swelling, 
and  general  and  local  reaction  are  greater  and  more  prolonged,  but 
very  rarely  end  in  suppuration. 

The  direct  implication  of  a  joint  in  a  fracture,  or  the  spread  to  it  of 
the  neighboring  reaction,  or  the  presence  of  a  concomitant  sprain,  as 
is  so  often  seen  at  the  knee  in  fractures  of  the  thigh,  adds  an  arthritis 
which  increases  the  pain  and  discomfort,  and  may  delay  recovery  or 
diminish  its  completeness. 

In  compound  fractures  with  a  small,  clean  wound  it  has  seemed  to  me 
that  the  local  and  general  reaction  is  even  less  than  in  simple  fracture, 
presumably  because  the  extra vasated  blood  escapes  through  the  wound, 
with  consequently  less  tension  and  less  absorption  of  fibrin-ferments  to 
cause  fever.  Under  appropriate  treatment  such  a  wound  heals  in  a 
few  days,  and  the  course  is  thenceforth  that  of  a  simple  fracture. 

In  compound  fractures  with  bruising  of  the  skin  that  prevents  pri- 
mary union  of  the  wound,  and  in  those  made  compound  by  the  slough- 
ing of  the  bruised  skin,  the  course  may  be  very  different.  It  is  that 
of  a  deep,  lacerated  wound,  from  whose  walls  sloughs  must  be  cast  off, 
and  in  which  suppuration  is  inevitable  and  serious  infection  possible. 
In  the  milder  forms  the  suppuration  is  slight  and  limited  to  the  super- 
ficial portions  of  the  wound,  and  the  course  is  practically  that  of  a 
simple  fracture  with  only  the  delay  due  to  tardier  union  of  the  bone 
and  cicatrization  of  the  wound.  But  in  the  severer  forms  all  the  local 
and  general  symptoms  are  more  marked,  the  swelling  is  greater,  the 
fever  higher  and  persistent.  If  treatment  fails  to  overcome  the  infec- 
tion the  pus  burrows  amid  the  muscles,  neighboring  abscesses  form, 
with  chills  and  exacerbation  of  the  fever,  and  amputation  may  be  indi- 
cated to  save  the  imperiled  life.     Or,  by  counter-openings,  drainage, 


THE  REPAIR   OF  FRACTURES  AXD   THE  CLINICAL   COURSE.    69 

and  the  free  use  of  antiseptics,  the  suppuration  may  be  brought  under 
control,  and  then  the  patient  pursues  his  weary  course  toward  conva- 
lescence through  the  pains  and  perils  of  the  slow  casting  off  of  necrotic 
fragments  of  the  bone  and  the  tardy  formation  and  ossification  of  the 
granulations  that  must  take  their  place.  Such  cases  are  often  despair- 
ingly slow  in  reaching  solid  union  and  closure  of  the  sinuses,  and  still 
longer  in  regaining  use  of  the  limb.  The  callus  is  large,  the  cicatrix 
adherent  and  sensitive,  the  adjoining  muscles  hampered  by  adhesions. 
The  condensation  of  the  callus  is  liable  to  become  extreme  in  portions 
because  of  the  prolongation  of  the  irritation,  and  thereby  to  cause  ])ar- 
tial  necroses  which  prolong  or  renew  the  suppuration  in  the  efforts  to 
cast  them  out,  so  that  the  sinuses  may  persist  intermittently  for  years, 
with  longer  or  shorter  interru})tions. 

Certain  moderate  angular  or  lateral  displacements  remaining  after 
incomplete  reduction  are  often  smoothed  out,  specially  in  the  young, 
in  the  course  of  a  year  or  two  by  the  rounding  oflP  of  prominent  points 
and  the  filling  of  hollows,  and  even  by  an  actual  change  in  the  axis  of 
the  bone,  effected  presumably  by  the  pull  of  the  muscles. 


CHAPTER  VI. 

COMPLICATIONS  AND  REMOTE  CONSEQUENCES. 

Early  Local  Complications :  Skin,  bloodvessels,  gangrene,  degeneration  of  mus- 
cles, suppuration.  Early  General  Complications  :  Septicaemia,  fat  embolism, 
delirium  tremens,  tetanus,  pneumonia.  Late  Local  Complications:  Excess- 
ive painful  callus,  tumor,  injury  of  nerve,  weak  callus,  arrest  or  exaggeration 
of  growth,  stiffness  of  joints,  atrophy,  thrombosis,  and  embolism. 

These  may  be  local  or  general,  and  the  complications  may  be  the 
direct  and  immediate  result  of  the  primary  violence  or  the  later  result 
of  the  primary  lesions,  of  infection,  or  of  constitutional  conditions. 
Some  are  peculiar  to  fractures,  others  may  arise  also  in  connection  with 
other  forms  of  injury. 

Early  Local  Complications. 

Skin.  The  sharp  point  of  the  upper  main  fragment  may  be  forced 
through  the  overlying  muscles  and  fascia  and  perforate  the  skin  or 
become  engaged  in  its  deeper  layers  in  such  a  way  that  its  reduction  is 
difficult,  or  it  may  make  such  pressure  upon  the  unbroken  skin  that 
the  latter  will  slough  at  the  point  of  pressure  in  the  course  of  a  few 
days.  The  first  condition  may  sometimes  be  corrected  by  traction  upon 
the  lower  segment  of  the  limb,  but  usually  an  incision  will  be  neces- 
sary to  effect  a  complete  reduction  of  the  displacement.  If  perforation 
has  taken  place  the  opening  should  be  at  once  enlarged,  for  this  does 
not  add  to  the  chance  of  infection,  and  greatly  simplifies  reduction. 

Pressure  upon  the  unbroken  skin  must  be  relieved  by  reduction,  or 
at  least  by  diminution  of  the  displacement ;  and  if  this  is  not  possible 
the  bone  should  be  exposed  by  incision  and  the  projecting  portion  cut 
away,  for  such  a  wound  can  be  so  protected  that  it  will  heal  promptly, 
while  one  made  by  sloughing  will  surely  suppurate,  and  even  if  danger- 
ous infection  thereby  of  the  seat  of  fracture  is  avoided,  yet  the  wound 
will  be  slow  to  heal,  and  will  leave  an  adherent  and  possibly  sensitive 
scar. 

The  sloughing  of  the  skin  contused  by  the  primary  violence  is  rare 
except  in  connection  with  compound  fracture — that  is,  violence  which 
is  sufficient  to  kill  the  skin  generally  breaks  it.  Theoretically,  it 
would  be  well  immediately  to  remove  all  skin  and  other  tissues  that 
have  been  thus  killed,  in  order  more  surely  to  avoid  infection  ;  but  the 
limits  of  such  destruction  cannot  be  determined  with  sufficient  accu- 
racy. A  fairly  accurate  estimate  of  the  probability  of  sloughing  and 
its  extent  can  be  made  by  applying  a  rubber  bandage  tightly  to  the 
limb  for  a  few  minutes,  as  in  producing  artificial  ischsemia  for  opera- 
(70) 


COMPLICATIONS  AND   REMOTE   CONSEQUENCES.  71 

tion,  and  noting  the  areas  which  do  not  share  in  the  bhish  following 
its  removal.  This  test  is  fairly  accnrate  except  for  areas  of  skin  on  the 
distal  side  of  long  transverse  wonnds  ;  such  generally  remain  pale,  even 
if  viable.  The  failure  of  blood  to  flow  on  minute  puncture  of  the  skin 
is  also  a  fairly  accurate  indication  of  its  death. 

Bloodvessels.  Rupture  or  serious  bruising  of  the  main  vessels  of  a 
limb  is  a  serious  but  infrequent  complication.  Among  the  more  impor- 
tant vessels  that  have  been  thus  injured  in  simple  fracture  are  the  mid- 
dle meningeal  and  carotid  arteries  in  fractures  of  the  skull,  the  sub- 
clavian vein  and  artery,  and  the  acromial  branch  of  the  acromio-thoracic 
artery  in  fractures  of  tlie  clavicle,  the  brachial  and  axillary  arterv  in 
fractures  of  the  humerus,  the  popliteal  artery  and  vein  in  those  of  the 
lower  end  of  the  femur,  and  the  anterior  tibial  in  those  of  the  leg. 
In  compound  fractures  the  same  vessels  and  also  those  lying  at  a 
greater  distance  from  the  bone  may  be  injured. 

The  rupture  of  an  artery  in  a  simple  fracture  may  lead  to  fatal 
hemorrhage,  even  if  the  vessel  is  a  small  one,  in  case  the  blood  can 
escape  into  a  large  natural  cavity,  as  in  a  unique  case  of  fatal  hemor- 
rhage following  rupture  of  a  small  branch  of  an  intercostal  artery  after 
fracture  of  a  rib ;  ^  but  in  a  limb  it  leads  either  to  the  formation  of  a 
traumatic  aneurism  or  to  gangrene.  The  rupture  may  be  immediate 
or  it  may  occur  after  a  few  days  by  sloughing  of  the  bruised  vessel. 

The  symptoms  are  a  rapidly  increasing  local  swelling,  which  pulsates 
after  it  has  ceased  to  increase,  and  (in  the  case  of  the  main  artery) 
absence  of  the  pulse  in  its  distal  branches.  Gangrene  is  more  directly 
due  to  interference  with  the  venous  flow  by  the  pressure  of  the  swelling 
than  to  loss  of  arterial  supply,  and  consequently  appears  in  the  "  moist" 
form,  characterized  by  swelling,  duskiness,  and  coolness  of  the  liml). 

The  object  of  early  treatment  is  to  check  the  hemorrhage  and  favor 
the  venous  flow  by  elevation  of  the  limb,  possibly  combined  with 
digital  pressure  upon  the  main  trunk  or  with  snug  bandaging  from  the 
lower  end  of  the  limb  to  a  point  well  above  tlie  injury.  If  a  well- 
defined  aneurism  forms  it  may  be  treated,  after  union  of  the  fracture 
has  taken  place  or  is  well  advanced,  by  proximal  or  local  ligature  of 
the  artery.  Possibly,  if  gangrene  threatened,  the  limb  might  be  saved 
by  a  free  incision  through  which  the  escaped  blood  could  be  turned 
out,  thus  relieving  the  pressure  on  the  veins,  and  by  tying  the  artery. 

In  compound  fractures  the  diagnosis  is  made  by  the  })r()fus('ness  and 
arterial  character  of  the  bleeding  ;  and  the  treatment  is  to  tie  the  artery 
at  the  point  of  injury.  But  it  not  infrequently  happens  that  after 
com})lete  rupture  of  arteries  as  large  even  as  the  femoral  the  hemor- 
rliage  promptly  ceases  spontaneously.  Bleeding  from  a  torn  vein  is 
more  persistent  and  often  profuse. 

Rupture  of  a  large  vein  cannot  be  certainly  recognized  in  a  simple 
fracture,  and  its  treatment  is  controlled  by  that  of  the  gangrene  which 
it  may  cause.  In  compound  fractures  the  vessels  may  sometimes  be 
seen  and  tied,  but  probably  the  associated  lesions  will  be  such  that 
amputation  will  be  indicated. 

Thrombosis  of  an  artery,  and  doubtless  also  of  a  vein,  maybe  caused 

'  London  Medical  Times  and  Gazette,  1860,  ii.,  p.  607. 


72  FRACTURES. 

by  the  direct  violence  which  causes  a  fracture.  I  have  seen  examples 
in  the  arteries  of  the  arm  and  leg  broken  by  the  passage  of  a  wheel,  the 
condition  being  found  on  examination  of  the  limb  after  amputation 
because  of  gangrene,  and  others  have  been  reported.  Thrombosis  of  a 
vein  mav  be  caused  by  the  pressure  of  a  displaced  fragment.  A  case 
involving  the  femoral  vein  and  ending  in  gangrene  and  amputation  is 
reported  in  the  Deutsche  med.  Wochenschrift,  June  8,  1892,  p.  549. 

Gangrene  may  be  local  or  general  :  the  former  the  result  of  crushing 
of  the  skin  and  other  soft  parts  in  direct  fracture,  the  latter  the  result 
of  injury  to  or  compression  of  the  vessels  or  of  tight  bandaging. 

Local  gangrene  is  manifested  by  the  darkening  and  hardening  of  an 
area  of  skin  surrounded  by  an  inflammatory  zone  ;  the  swelling  and 
fever  are  more  marked  and  persistent,  and  when  the  dry  patch  is  split 
or  cut  away  an  abundant  thin,  pink  or  dark,  and  oifensive  exudate 
escapes  from  beneath  it  and  from  the  adjoining  subcutaneous  and  inter- 
muscular planes.  The  infection  must  be  combatted  by  free  removal  of 
the  dead  and  dying  tissues,  irrigation,  and  drainage.  The  danger  of 
general  infection  is  great,  and  amputation  is  often  required  to  save  life. 

Gangrene  of  the  limbs  is  usually  of  the  moist  form  and  begins  with 
coolness  and  discoloration  of  the  toes  or  fingers,  the  latter  beginning 
as  a  deep-red  color,  and  soon  changing  to  purple  and  grayish-black. 
Dark  blebs  may  appear  on  the  surface,  or  the  epidermis  may  be  exten- 
sively but  slightly  raised  by  a  thin,  dark  serum.  If  taken  in  time, 
and  if  the  cause  can  be  removed,  as  in  tight  bandaging,  the  life  of  the 
part  may  be  preserved,  and  I  have  thought  that  keeping  the  limb  in 
hot  water  (100°  to  102°  F.)  was  helpful ;  but  the  vitality  of  the  skin 
is  greater  than  that  of  the  muscles,  so  that  even  if  the  circulation 
returns  in  the  former  the  muscles  may  yet  disintegrate  and  the  limb 
be  lost.  I  saw  this  result  in  a  case  of  fracture  of  the  olecranon  which 
had  been  treated  by  the  immediate  application  of  a  plaster-of-Paris 
dressing.  The  patient  entered  the  hospital  on  the  fifth  day,  with  the 
uncovered  hand  black  and  swollen ;  the  dressing  was  removed,  and  the 
limb  placed  in  a  hot  bath.  Two  days  later  circulation  was  re-estab- 
lished in  the  skin  of  the  hand  and  forearm,  but  a  week  later  incisions 
had  to  be  made  in  the  forearm,  through  which  the  muscles  appeared 
wholly  disorganized  and  diflQuent. 

It  must  be  borne  in  mind  that  even  a  narrow  circular  constriction, 
as  by  a  band  of  adhesive  plaster,  is  sufficient  to  produce  this  disastrous 
result,  and  is,  perhaps,  even  more  likely  to  do  so  than  an  equally  tight 
bandage  covering  the  limb.  Consequently  the  longitudinal  strips  of 
plaster  used  in  making  traction  should  not  be  reinforced  by  the  circular 
strips  which  are  sometimes  applied  with  the  idea  of  keeping  the  former 
more  securely  in  place. 

Degeneration  and  contraction  of  the  muscles,  the  result  of  arrested 
blood-supply  by  bandagmg  or  injury  to  the  arteries,  or  (Bardenheuer^ 
and  ^Nlurphy'-)  of  a  venous  stasis  due  to  the  traiuna,  is  occasionally  seen. 
Froelich^  reports  two  cases  in  which  it  was  caused  by  circular  con- 

'  Bardenheuer:  Deutsche  Zeitschrif t  ftir  Chir.,  vol.  cviii.,  p.  44. 

2  Murphy:  Jour.  Am.  Med.  Ass.,  Oct.,   1914,  p.   1249. 

3  FroeUch:  Arch.  gen.  de  Chir.,  1909,  vol.  iii.,  p.  445. 


COMPLICATIONS  AND  REMOTE  CONSEQUENCES.  73 

striction.  I  have  seen  one,  and  Murphy  refers  to  others,  in  which  it  \\as 
caused  by  flexion  of  the  elbow  in  treatment  of  a  supracondylar  fracture. 
A'olkmann,  who  first  described  it,  gave  it  the  name  of  "  ischemic  con- 
traction." It  is  most  frequently  (perhaps  exclusively)  seen  in  the 
young  and  in  the  forearm  after  fracture  of  the  radius  and  ulna  or  supra- 
condylar fracture  of  the  humerus,  and  is  marked  by  atrophy  and  short- 
ening of  the  muscles,  the  fingers  being  permanently  flexed.  This  change 
is  brought  about  by  an  interstitial  myositis.  It  is  to  be  distinguished 
from  similar  contractures  due  to  nerve  injury  or  disease  by  its  prompt 
appearance  and  severe  premonitory  pain.  Persistent  efforts  to  lengthen 
the  muscles  by  elastic  apparatus  and  manual  straightening  of  the  fingers 
have  yielded  a  number  of  good  results.  Hildebrand,^  who  had  noticed 
signs  of  involvement  of  the  nerves,  obtained  partial  relief  in  three  cases 
by  removing  the  nerve  trunks  from  among  the  shrunken  muscles  and 
lodging  them  between  the  fascia  and  the  skin.  Kleinschmidt  and  Hoft'a^ 
and  Froelich  got  good  results  by  excising  about  an  inch  of  the  radius 
and  ulna,  thus  giving  the  flexor  muscles  adequate  length. 

Suppuration  in  simple  fractures  is  very  rare,  and  when  it  occurs  it 
appears  to  be  due  to  auto-infection,  by  germs  carried  by  the  blood  and 
possibly  brought  fi'om  some  suppurating  focus  in  a  distant  portion  of 
the  body,  as  a  furuncle ;  rough  handling  of  the  broken  limb  and 
neglect  of  proper  care  apparently  favor  its  occurrence.  It  promptly 
makes  the  fracture  compound  by  spontaneous  or  surgical  opening,  and 
the  course  and  prognosis  are  then  those  of  an  open  infected  fracture. 

Suppuration  in  compound  fractures  can  generally  be  prevented  or 
restricted  to  the  superficial  layers  when  the  wound  is  small  and  its 
edges  not  contused,  as  is  ordinarily  the  case  in  fractures  by  indirect 
violence.  The  later  its  appearance,  the  less  likely  is  it  to  spread  widely 
among  the  muscles  and  endanger  life. 

In  compound  fracture  with  bruising  and  extensive  laceration,  sup- 
puration may  remain  as  a  local  complication,  the  pus  escaping  freely 
to  the  exterior  and  the  infection  not  spreading ;  the  graver  cases  will 
be  considered  in  the  following  section. 

Early  General  Complications. 

Septicsemia.  Septic  infections  occur  in  various  forms  and  widely 
dift'ering  degrees  of  severity.  The  rarest  and  most  fatal  is  one  seen 
also  after  other  injuries  and  known  by  several  names  which  indicate 
its  more  striking  s\Tnptoms — bronzed  erysipelas,  emyhysematims  ganf/roic, 
malignant  oedema,  fuJgurant  septicoemia.  It  is  due  to  an  anaerobic  germ 
named  "vibrion  septique"  by  Pasteur,  and  now  termed  "B.  oedematis 
maligni."  Its  course  is  very  rapid,  leading  almost  always  to  death 
within  a  few  hours.  It  is  marked  by  a  rapidly  spreading  bronzed 
discoloration  and  subcutaneous  oedema  and  emphysema  due  to  the 
development  of  a  very  offensive  gas.  This  emphysema  can  be  recog- 
nized by  fine  crackling  on  palpation,  often  at  some  distance  beyond  the 

iHildcbrand:    SammlunK  klin.  VortriiKe.  1906,  Chir.    No.  122. 
2  Kleinschmidt  and  Hoffa  :  Zentralblatt  fiir  Chir.,  1907,  p.  81. 


74  FRACTURES. 

discoloration.  The  infection  is  so  virulent  that  our  art  is  practically 
powerless  against  it ;  a  very  early  high  amputation  may  perhaps  save, 
especially  if  combined  with  free  injection  into  the  tissues  of  the  stump 
of  hydrogen  peroxide  or  oxygen. 

Gas  Bacillus  Infection.  Gas  bacillus  infection,  long  known  as  an 
infrequent  complication  in  civil  surgery,  has  come  into  prominence 
by  its  great  frequency  recently  among  the  wounded  from  the  battle- 
fields of  Belgium  and  France.  A  full  study  of  it  has  not  yet  appeared. ^ 
Apparently  several  different  germs  may  cause  it,  but  the  most  common 
is  the  B.  capsulatus  aerogenes  (Welch).  At  first  the  mortality  was  very 
great,  more  than  50  per  cent.,  but  in  the  second  year  of  the  war  it  was 
brought  under  better  control.  The  skin  adjoining  the  wound  is  darkly 
discolored,  the  torn  tissues  are  gray  and  dry,  and  an  abundant  thin 
offensive  discharge  containing  bubbles  of  gas  flows  from  the  wound. 
Emphysematous  crackling  may  be  felt.  The  common  antiseptics 
proved  at  first  to  be  inadequate,  but  the  addition  of  free  enlargement  of 
the  wound  and  abundant  provision  for  drainage  brought  much  better 
results.  Free  washing  with  hypochlorite  of  soda,  "Dakin's  solution" 
(p.  126)  was  also  very  helpful.  I  am  disposed  to  think  that  the  main 
factor  of  success  is  the  meticulous  attention  of  the  surgeon  to  drainage 
and  dressing,  aided,  of  course,  by  antiseptics.  Dr.  Blake  told  me  he 
had  found  a  1  per  cent,  solution  of  hydrochlorate  of  quinine  effective. 
Ombredanne  recommends  irrigation  with  ether,  followed  by  packing 
with  gauze  soaked  in  ether.  Krieger  saved  one  case  with  a  serum  pre- 
pared by  Weinberg  of  the  Institut  Pasteur  with  a  culture  of  B. 
perfringens. 

In  the  less  acute  forms  septic  infection  follows  the  establishment  of 
suppuration  and  is  less  marked  locally  and  generally.  The  limb  swells 
and  becomes  discolored,  but  the  color  is  a  dusky  red  and  its  area  is 
limited  ;  the  swelling  is  more  like  the  common  inflammatory  bogginess, 
and  incisions  into  it  give  exit  to  pus  or  inflammatory  serum  which  has 
not  the  odor  of  decomposition.  Such  processes  may  be  arrested  by 
free  incisions,  drainage,  and  antiseptics;  but  complete  recovery  is  long 
delayed  by  necrosis  of  the  ends  of  the  fragments. 

Fat  Embolism.  As  has  been  stated  in  Chapter  III.,  free  fat  can  fre- 
quently be  found  in  the  urine  during  the  first  two  or  three  days  after 
fracture.  It  is  reasonable  to  suppose  that  it  comes  from  the  lacerated 
marrow,  entering  the  circulation  either  directly  through  the  torn  and 
gaping  veins  of  the  bone  or  through  the  lymphatics.  When  thus 
taken  up  in  considerable  quantities  it  may  be  arrested  in  the  pul- 
monary capillaries  or,  after  having  passed  through  those,  in  the  capil- 
laries of  the  systemic  circulation,  and  occasion  serious  symptoms  or 
even  death.  Although  the  subject  has  been  studied  by  several,  by 
observation  and  experiment,  since  Von  Recklinghausen  first  noted  it 
in  1884  as  a  cause  of  death  by  plugging  the  pulmonary  capillaries,  its 
symptomatology  is  not  at  all   clear,  presumably  because  it  is  masked 

I  For  an  abstract  of  current  discussions  see  Year  Book,  Practical  Med.  Series,  1916, 
Vol.  2,  p.  1136. 


COMPLICATIONS  AND  REMOTE  CONSEQUENCES.  75 

by  the  functional  disturbances  created  by  its  interference  with  the 
circulation  in  various  organs,  notably  the  brain.  There  is  even  reason 
to  think  that  it  has  something,  ])erhaps  much,  to  do  in  some  eases 
with  the  phenomena  classed  as  shock,  with  delirium  tremens,  which  is 
so  much  more  common  after  fractures  than  after  other  injuries,  and 
with  the  pulmonary  oedema  and  early  pneumonias  of  the  alcoholic 
and  aged. 

The  pathological  conditions  revealed  on  autopsy  are  cedema  of  the 
lungs  and  extensive  plugging  of  the  pulmonary  capillaries,  and 
sometimes  even  of  the  arterioles,  with  free  fat,  similar  but  less  ex- 
tensive plugging  of  the  systemic  capillaries,  often  marked  by  small 
hemorrhages,  and  sometimes  extensive  filling  of  the  renal  glomeruli. 
The  local  reaction  is  that  of  the  beginning  of  infarction,  and  probably 
in  the  cases  which  survive  it  is  arrested  by  the  prompt  forcing  of  the 
fat  through  the  capillaries  and  the  re-establishment  of  the  circulation. 
Since  the  emboli  are  not  septic  the  element  of  infection  does  not  enter 
into  the  case,  and  death  is  due  to  the  mechanical  interference  with 
the  nutrition  and  functions  of  the  parts  involved. 

The  symptoms  in  well-defined  cases  confirmed  by  autopsy  have 
begun  Avithin  twenty-fimr  hours  after  the  injury,  rarely  after  two  or 
three  days,  and  usually  with  quickening  of  the  respiration  that  some- 
times become  marked  dyspnoea;  undiminished  resonance  of  the  chest 
and  abundant,  coarse  rales  ;  little  or  no  fever ;  face  at  first  pale,  then 
cyanotic ;  unconsciousness  followed,  and  death  within  a  few  hours. 
In  other  cases  the  central  nervous  symptoms  have  been  the  most 
prominent :  unconsciousness,  noisy  and  slow  breathing,  muscular 
twitching,  and  even  convulsions,  and  sometimes  paralyses.  Most 
tragical  are  those  cases,  fortunately  very  rare,  in  which  the  complica- 
tion proves  rapidly  fatal  in  a  young  and  healthy  patient  after  a  simple, 
comparatively  unimportant  fracture,  such  as  a  Pott's  at  the  ankle, 
with  which  the  idea  of  danger  to  life  is  not  associated. 

Treatment  is  apparently  almost  powerless  to  help ;  the  indications 
are  to  prevent  further  crushing  of  the  marrow  by  immobilization  of 
the  limb,  to  stimulate  the  heart,  and  to  aid  the  respiration  by  inhala- 
tions of  oxygen  when  dyspnoea  is  present. 

Delirium  tremens  is  a  not  infrequent  complication  of  fracture  in  hos- 
pital cases.  The  course  is  less  severe  and  the  prognosis  better  than 
in  cases  not  excited  by  traumatism.  Its  occurrence  appears  to  be 
favored  not  only  by  the  traumatism,  but  also  by  the  withdrawal  of 
the  customary  stimulant  which  usually  follows  admission  to  a  hospital, 
and  I  have  found  it  advisable,  therefore,  as  routine  practice  to  give 
alcohol  in  moderate  quantities  during  the  first  week  to  those  injured 
who  are  habitual,  even  if  not  excessive,  drinkers.  The  attack  begins 
with  restlessness  and  sleeplessness,  and  when  fully  developed  presents 
the  usual  symptoms.  In  addition  to  alcohol,  sedatives  are  indicated, 
together  with  cathartics  and  a  light,  nutritious  diet.  Usually  the  attack 
subsides  after  one  good   night's  rest  has   been  obtained. 

Tetanus  is  a  rare  complication,  almost  unknown    in  simple  fractures 
and    much  more    frequent   in  compound    fractures   of  the   hand  and 
fingers  than   in   those  of  other  bones.     Excluding  those  of  the  hand 
6 


76  FRACTURES. 

and  fingers,  I  have  seen  it  only  in  one  fracture  of  the  femur  (gunshot) 
and  in  two  of  the  forearm  (compound).  AUhough  the  microbic  nature 
of  the  disease  has  been  established,  it  is  noteworthy  that  many  of  the 
attacks  are  preceded  by  a  sudden  fall  in  the  temperature  of  the  air. 
One  of  my  cases  developed  after  such  a  fall,  and  on  the  same  day  two 
cases  occurred  in  two  other  hospitals  in  the  city. 

Pneumonia,  developing  on  the  second  or  third  day,  is  a  rather  fre- 
quent and  dangerous  complication.  Reference  has  been  made  to  its 
possible  origin  in  fat  embolism  of  the  lungs.  It  begins  more  fre- 
quently without  a  chill  than  with  one,  and,  in  our  hospital  cases  at 
least,  is  likely  to  run  a  rapid,  severe  course,  with  high  fever  and 
delirium,  often  terminating  fatally  in  three  or  four  days. 

Pneumonia  appears  also  as  a  late  complication  in  the  old  and  feeble, 
beginning  insidiously,  and  pursuing  an  asthenic  course,  with  moderate 
fever  and  mild  delirium,  and  ending  usually  in  unconsciousness  and 
death.  Prolonged  recumbency  is  thought  to  favor  its  occurrence  by 
promoting  venous  congestion  of  the  lungs,  but  it  appears  to  me  to  be 
rather  a  relatively  unimportant  incident  in  a  general  failing  of  the 
strength  which  is  usually  manifest  a  few  days  before  the  signs  of  con- 
solidation appear,  and  to  which  the  death  appears  to  be  due  quite  as 
much  as  to  the  pueumonia.  I  have  learned  to  look  for  this  change 
especially  in  fractures  of  the  neck  of  the  femur  in  the  old  and  feeble. 

Late  Local  Complications. 

The  callus  may  be  excessive,  ■painful,  or  iveah,  or  may  become  the 
seat  of  a  sarcoma.  A  callus  may  be  unusually  large,  "  exuberant," 
either  because  the  fragments  remain  widely  displaced  during  repair, 
or  because  ossification  extends  far  beyond  the  usual  limits,  or  because 
the  presence  of  a  necrotic  fragment  maintains  irritation  and  delays  the 
termination  of  the  productive  process.  The  first  variety  is  not  prop- 
erly to  be  termed  a  complication,  for  the  size  of  the  callus  is  necessary 
to  firm  union.  The  second  is  seen  especially  in  the  neighborhood  of 
joints,  as  the  result  of  the  persistent  displacement  of  a  fragment,  or  of 
ossification  of  muscular  attachments,  ligaments,  or  capsule  in  the  old, 
or  of  exaggerated  productive  activity  of  the  periosteum  in  the  young. 
The  third  is  rather  common  after  compound  fractures  that  have  sup- 
purated. 

Enlargement  near  a  joint  may  mechanically  restrict  its  range  of 
motion,  and  at  other  points  it  may,  in  like  manner,  interfere  with  the 
action  of  a  muscle  or  make  disabling  pressure  upon  a  nerve  or  inter- 
fere with  the  venous  circulation  in  the  limb. 

An  exuberant  callus  may,  and  usually  does,  diminish  in  size,  but 
not  sufficiently  to  remove  marked  obstacles  to  function.  Such  removal 
can  be  effected  only  by  surgical  measures,  the  cutting  away  of  the 
exuberant  mass;  local  applications  made  to  the  surface  with  the  object 
of  promoting  its  aosorption  are  useless.  The  same  pressure -effects 
can  be  produced  by  persistent  displacement  of  the  fragments,  and  it 
is  not  always  possible  to  determine,  previous  to  operation,  whether 
the  offending  mass  is  a  fragment  or  the  callus. 


COMPLICATIONS  AND  REMOTE  CONSEQUENCES. 


77 


Painfulness  of  the  callus  may  begin  early  in  the  course  of  repair 
and  persist  long  after  union  has  become  complete,  or  it  may  begin 
after  an  interval,  sometimes  a  very  long  one.  Many  patients  com- 
plain of  dull  pain  in  the  limb  for  months,  even  for  years,  after  the 
injury,  especially  after  prolonged  use  and  in  connection  with  changes 
in  the  weather,  but  the  cases  in  which  the  pain  is  limited  to  the  callus 
are  rare.  The  late  form,  that  in  which  the  pain  begins  after  an  in- 
terval, is  clearly  inflammatory,  the  inflammation  being  generally  a 
recurrence  in  an  old  suppurative  focus,  manifesting  itself  by  fever, 
swelling,  and  tenderness,  and  relieved  by  spontaneous  or  surgical 
evacuation  of  the  pus. 


Fig.  35. 


Fig.  36. 


Intra-articular  fracture  of  the  lower  end 
of  the  humerus,  wiih  exuberant  callus, 
especially  in  front. 


Exuberant  callus  ;  fracture  of  lower  end 
of  humerus. 


The  early  continuous  form  is  not  inflammatory,  but  the  causes  are 
not  always  clear.  The  pain  has  been  attributed  to  pressure  upon  a 
nerve  either  without  or  within  the  callus,  to  a  neuritis  set  up  by  in- 
jury of  a  nerve  at  the  time  of  the  accident,  as  is  seen  also  after  wounds 
involving  only  the  soft  parts,  and  to  a  supposed  persistent  osteitis  or 
an  osteo-neuralgia  (Gosselin)  the  cause  of  which  is  equally  conjectural. 
The  pain  may  be  continuous  or  intermittent,  and  exacerbated  at  night 
or  by  change  in  the  weather.  It  must  be  distinguished  from  pain  due 
to  injury  of,  or  pressure  upon,  a  nerve. 

Counter-irritation  on  the  surface  has  given  relief,  and  I  should  think 
that  in  the  rebellious  cases  it  might  be  advisable  to  incise  the  perios- 
teum or  to  cut  into  or  chisel  away  the  bone. 

The  development  of  a  tumor,  sarcoma,  at  the  site  of  a  healed  frac- 
ture, within  a  few  weeks  or  after  an  interval  of  several  years,  has  been 
occasionally  observed,  and  apparently  belongs  in  the  same  etiological 
group  as  that  of  sarcomata  following  other  injuries  of  bone  or  soft 


78  FRACTURES. 

tissues.  Stiil  rarer  is  the  development  of  carcinoma  after  fracture  in 
those  who  have  or  have  had  a  carcinoma  at  another  point.  Pearce 
Gould  (Lancet,  April  25,  1896)  refers  to  one  such  case,  fracture  of  the 
humerus  in  a  lady  whose  breast  had  been  removed  for  carcinoma  five 
years  previously  ;  he  explored  very  carefully  by  operation,  without 
finding  any  sign  of  tumor ;  "  two  months  later  an  extensive  growth 
had  appeared  at  the  seat  of  fracture." 

Associated  Injury  of  a  Nerve.  A  nerve  may  be  bruised  or  completely 
ruptured  at  the  time  of  the  accident,  or  it  may  become  stretched  over 
the  edge  of  a  fragment  or  by  the  growing  callus,  or  compressed  within 
a  more  or  less  complete  canal  formed  about  it  by  the  callus  or  by  cica- 
tricial tissue  developed  in  the  soft  parts.  Primary  rupture  of  a  motor 
nerve  is  liable  to  be  overlooked  at  first,  because  of  the  withdrawal  of 
the  limb  from  use  in  consequence  of  the  fracture,  but  it  is  not  prob- 
able that  the  resultant  delay  diminishes  the  chance  of  successfully 
uniting  the  divided  portions  by  operation,  and  on  some  accounts  the 
operation  is  more  free  from  risk  if  not  undertaken  until  after  the  frac- 
ture has  become  united.  The  diagnosis  of  rupture  cannot  always  be 
safely  made  on  immediate  paralysis  of  the  muscles  supplied  by  the 
nerve.  I  once  operated  upon  a  case  of  supposed  rupture  of  the 
musculo-spiral  nerve  in  connection  with  fracture  of  the  shaft  of  the 
humerus,  and  found  the  nerve  untorn  and  apparently  uninjured  for 
some  distance  above  and  below  the  fracture.  It  must  also  not  be 
hastily  assumed  that  an  operation  to  reunite  the  nerve  has  failed ;  in 
two  cases  (nuisculo-spiral  nerve)  I  have  seen  function  return  after 
nearly  a  year  had  elapsed  since  the  operation.  Els,^  studying  musculo- 
spiral  paralysis  after  fracture  of  the  humerus,  on  the  basis  of  Von 
Bruns's  observations,  states  that  complete  rupture  is  much  less  frequent 
than  bruising  or  late  compression,  only  3  out  of  73  cases.  He  says 
sensibility  is  often  preserved,  except  in  a  sraaH  area  between  the  first 
and  second  metacarpals.  He  refers  to  cases  in  which  an  adjoining 
cicatrix  had  so  invacled  the  nerve  that  multiple  longitudinal  incisions 
with  separation  of  the  fibres  of  the  nerve  were  required. 

The  compression  of  a  nerve  by  a  displaced  fragment  may  abolish  its 
functions  or  may  excite  a  neuritis  manifested  by  modifications  of  sensi- 
bility and  sometimes  by  great  pain  ;  similar  effects  may  be  produced 
by  a  coincident  contusion  of  the  nerve.  The  most  frequent  examples 
are  in  fractures  above  the  elbow  and  above  and  below  the  knee  ;  occa- 
sionally it  is  seen  in  fractures  of  the  clavicle,  upper  end  of  the  humerus, 
and  pelvis. 

Similar  compression  may  be  made  by  the  callus  upon  a  nerve  which 
crosses  or  passes  through  it.  Of  late  years  a  number  of  such  cases 
have  been  operated  upon,  and  various  gross  changes  noted  in  the  nerve, 
which  is  usually  reduced  in  size  for  a  greater  or  less  distance  below  and 
shows  a  notable  enlargement  just  above  tlie  point  of  pressure. 

The  treatment  consists  in  the  removal  of  the  corresponding  portion 
of  the  bone  or  callus,  and  this  should  be  done  freely.    The  nerve  should 

1  Els:  Beitrage  zur  klin.  Chir.,  1910,  vol.  Ixviii.,  p.  394. 


COMPLICATIONS  AND  REMOTE  CONSEQUENCES.  79 

also  be  separated  from  the  cut  surface  of  bone  by  interposition  of  the 
soft  parts. 

Weakness  of  the  callus,  which  should  not  be  confounded  with  delay 
in  consolidation,  is  manifested  in  two  ways :  by  its  yielding  under  use 
of  the  limb  after  union,  as  judged  by  the  usual  tests,  has  appeared  to 
be  complete,  and  by  a  later  loss  of  its  strength  under  the  influence  of 
intercurrent  local  or  general  causes;  the  latter  is  also  termed  soften! iir/ 
or  absorption  of  the  callus,  and  in  either  case,  if  fracture  occurs,  it 
is  termed  secondary  fracture.  The  weakness  may  be  due  to  insuffi- 
ciency in  the  amount  of  the  callus,  as  when  a  gap  has  been  created 
between  the  principal  fragments  by  their  displacement  or  by  loss  of 
bone,  or  in  the  ossification  of  the  bond  uniting  the  fragments.  In 
either  case  the  bony  bridge  uniting  the  fragments  is  not  strong  enough 
to  bear  the  strain  of  use,  and  it  either  breaks  completely  or  yields 
enough  to  permit  an  angular  displacement. 

Softening  of  the  callus  under  the  influence  of  a  general  disease — 
e.  g.,  scurvy,  typhoid  fever,  erysipelas — has  been  observed  in  a  few 
cases,  sometimes  after  the  lapse  of  many  months.  Clarke,  quoted  in 
the  Traite  de  Chirurgie,  reported  a  case  in  which  the  softening  ap- 
peared to  be  the  result  of  overwork  in  school.  The  callus  has  been 
felt  to  diminish  in  size,  and  abnormal  mobility  to  reappear  without  the 
intervention  of  any  violence. 

Secondary,  or  "  iterative,"  fracture  without  apparent  defect  or 
change  in  the  callus  is  a  not  infrequent  accident  due  to  premature  use 
of  the  limb  or  to  slight  external  violence.  Gosselin  tells  of  a  man 
twenty-five  years  old  who  broke  his  femur  six  times  in  twenty 
months  ;  the  fractures  occurred  in  the  second  week  after  he  began  to 
walk  and  in  consequence  of  a  slight  effort,  as  in  dancing,  running, 
and  trying  to  avoid  a  fall  ;  each  time  the  patient  had  left  his  bed  on 
the  forty-fifth  day.  The  symptoms  are  those  of  primary  fracture, 
but  usually  less  marked.. 

Arrest  of  growth  of  the  bone  is  occasionally  observed  in  the  young 
after  fracture  at  or  near  the  epiphyseal  cartilage.  (See  Separation  of 
the  Epiphyses,  Chapter  II.) 

Exaggeration  of  growth  of  the  bone  after  fracture  has  been  observed 
in  a  very  few  cases,  in  consequence  either  of  stimulation  of  the  epi- 
physeal cartilage  to  greater  activity  or  of  exaggerated  produ(;tion  of 
l)one  at  the  fracture.  Cases  have  been  reported  in  which  a  consider- 
able shortening  noted  immediately  after  recovery  has  disappeared  in 
the  course  of  a  year  or  two.  There  is  usually  room  in  sucli  cases  for 
some  doubt  of  the  accuracy  of  the  observation.  Enlargement  of  the 
patella  after  close  reunion  by  operation  has  been  observed  in  a  number 
of  cases,  both  in  breadth  and  length. 

Stiffness  of  the  joints  of  the  injured  limb  is  habitually  seen  after 
fracture,  and  involves  not  only  those  of  which  the  broken  bone  forms 
])art  but  also  those  at  a  distance  from  it,  especially  on  the  distal  side. 
It  is  most  marked  in  the  old  and  rheumatic  and  in  joints  directly  in- 
volved in  the  fracture  or  coincidontly  s])rained.  It  apju'ars  promptly 
aft(>r  the  accident,  is  most  marked  when  the  s])lints  are  removed 
(unless    measures    have   meanwhile  l)een   taken   to  relieve   it),  and    in 


80  FRACTURES. 

most  cases  disappears  slowly  under  use  of  the  limb.  If  a  joint  is 
involved  in  the  fracture,  or  otherwise  injured  at  the  moment  of  tlie 
accident,  a  traumatic  arthritis  may  follow  and  the  resultant  stiffness 
may  be  permanent ;  and  in  the  old  and  rheumatic  more  or  less  limita- 
tion of  motion  may  remain  even  when  the  joint  has  not  been  directly 
injured. 

The  causes  of  the  stiffness,  exclusive  of  direct  injury  of  the  joint, 
are  to  be  found  in  injury  of  the  muscles,  oedema,  and  shortening  and 
loss  of  elasticity  in  the  peri-articular  tissues,  sometimes  because  of 
their  implication  in  the  irritative  reaction  following  the  injury,  and 
sometimes  because  of  the  enforced  quiet.  This  stiffness  may  be  per- 
manent, in  whole  or  in  part,  when  the  periarticular  tissues  are  perma- 
nently shortened  by  cicatricial  change,  or  when  a  muscle  moving  the 
joint  has  undergone  marked  fibrous  cicatricial  change  or  has  become 
abnormally  attached  to  the  callus.  This  is  more  common  in  compound 
fractures  that  have  suppurated  than  after  simple  fracture.  Stiffness  of 
the  knee  and  ankle  after  fracture  of  the  thighs  of  the  elbow  after  fracture 
of  the  arm,  and  of  the  wrist  and  fingers  after  fracture  of  the  forearm  is 
constant  and  often  very  persistent.  It  is  relieved  by  measures  which 
diminish  the  oedema  and  improve  the  circulation,  and  these  may  some- 
times be  employed  before  consolidation  of  the  fracture  is  complete: 
such  are  massage,  passive  motion,  and  position.  The  fingers  stiffen, 
and  sometimes  very  rebelliously,  under  immobilization,  and  especially 
when  kept  fully  extended.  The  rule  should  therefore  be,  in  all 
injuries  of  the  upper  extremities,  to  leave  them  free  of  the  dressings 
whenever  that  is  possible  and  to  instruct  the  patient  to  move  them 
frequently ;  when  they  must  be  confined  the  position  of  flexion  for 
the  fingers  and  abduction  for  the  thumb  is  to  be  preferred. 

Persistent  active  and  passive  motion  of  the  joints  within  their  ex- 
isting range,  massage  and  hot  and  cold  douching  will  usually  increase 
the  range  and  freedom  rapidly  ;  in  the  young  and  young  adults  little 
time  will  be  lost  by  simply  trusting  to  the  natural  use  of  the  limb  to 
restore  its  functions.  Patients  should  be  encouraged  to  disregard 
pain  following  use  which  does  not  leave  the  joint  tender  the  next  day. 
Limitation  of  motion  due  to  displaced  fragments  or  overgrowth  of 
callus  can  be  relieved,  if  at  all,  only  by  operation. 

Atrophy  of  the  Muscles.  A  limb  that  has  long  been  withdrawn 
from  use  because  of  fracture  appears  smaller  above  the  seat  of  the 
injury,  and  also  below  it  if  the  oedema  has  disappeared.  Advantage 
has  been  taken  of  the  death  of  a  few  patients  at  this  perio:l  to  weigh 
their  muscles,  and  they  have  been  found  distinctly,  and  in  some  cases 
notably,  smaller  than  those  of  the  opposite  limb,  the  loss  involving 
all  and  not  merely  those  of  some  group  supplied  by  a  nerve  that  might 
have  been  injured.  In  the  young  and  in  young  adults  the  loss  is 
soon  made  good,  but  in  others  and  in  cases  of  long  duration  the  atrophy 
may  persist  for  months  or  even  be  permanent.  Various  explanations 
have  been  offered,  such  as  lack  of  use,  occlusion  in  fixed  dressings, 
diversion  of  nutritive  materials  to  form  the  callus,  and  reflex  trophic 
disturbances  from  injured  nerve  branches,  but  none  is  free  from  serious 


COMPLICATIONS  AND  REMOTE  CONSEQUENCES.  81 

objections.    Massage,  electricity,  and  systematic  exercise  are  the  meas- 
ures employed  to  hasten  or  effect  recovery. 

Thrombosis  of  the  Veins  and  Embolism.  Thrombosis  of  some  of  the 
larger  veins  in  the  neighborhood  of  a  fracture  is  thought  to  be  rather 
common  and  to  be  the  cause  of  the  oedema  and  venous  congestion 
which  are  so  constant  and  troublesome  after  fracture  of  the  lower 
limb  Avhen  the  patient  begins  to  M^alk.  Occasionally,  but  very  rarelv, 
the  process  occupies  or  extends  into  a  vein  sufficiently  large  to  furnish  an 
embolus  which  is  carried  to  the  heart  or,  more  commonly,  through  it 
into  the  pulmonary  artery,  and  causes  death,  Virchow  published  in 
1846  such  a  case  following  fracture  of  the  neck  of  the  femur,  and 
Durodie^  collected  eight  other  cases  in  which  the  deaths  occurred  be- 
tween the  sixteenth  and  fifty-seventh  days.  One  fracture  was  of  the 
femur,  the  others  of  the  leg.  Wilde ^  reported  two  cases  and  collected 
five  others;  and  Smirnow^  reported  one  and  collected  thirty-seven 
reported  cases. 

The  symptoms  are  the  usual  ones  of  pulmonary  embolism  :  sudden 
onset,  with  lividity  or  pallor,  dyspnoea,  prsecordial  distress,  and  death 
in  a  few  minutes. 

Conner^  has  shown  that  in  typhoid  fever  small  emboli  in  the  lungs, 
causing  local  consolidations  and  pleurisy  a  week  or  more  before  a 
thrombus  can  be  recognized  in  a  limb,  are  frequent;  and  the  inference 
is  plausible  that  they  may  similarly  occur  after  fracfeure,  and  may  be 
one  of  the  causes  of  the  so-called  hypostatic  pneumonias  which  (are 
so  feared  and  which  have  heretofore  been  generally  attributed  to 
recumbency. 

Arteries.  Traumatic  aneurysm  is  a  rare  complication.  H.  Meyer"* 
collected  sixty  reported  cases  and  added  one  of  an  intercostal  artery 
after  fracture  of  a  rib.  Thrombosis  of  an  artery,  because  of  coincident 
bruising,  is  more  common. 

1  Durodie:  ;&tude  sur  les  Thromboses  et  I'Einbolie  veineuses  dans  les  Contusions  et 
les  Fractures,  TMse  de  Paris,  1784,  No.  326. 

2  Wilde:  Centralb.  fur  Chir.,  1902,  p.  1349. 

3  Smirnow:  Ibid.,  1903,  p.  825. 

*  Meyer:  Inaug.  Dissert.,  Kiel,  1903;  Centralb.  fiir  Chir.,  1903,  p.  819. 
6  Conner:  Arch.  Int.  Med.,  1912,  vol.  x.,  p.  534. 


CHAPTER  VII. 

TREATMENT. 

Reduction.  Retention:  Removable  Dressings,  Permanent  Dressings,  Direct  Fix- 
ation. Massage.  Ambulatory  Treatment.  Management  of  Joints.  Com- 
pound Fractures.  Amputation.  Compound  Articular  Fractures,  General 
Treatment. 

The  treatment  of  a  fracture  is  in  the  main  a  mechanical  problem, 
simple  or  complex:  to  employ  mechanical  means  to  produce  physical 
results  (reduction)  or  to  oppose  the  displacing  action  of  mechanical 
forces  (retention).  The  surgeon  who  wishes  to  treat  a  case  intelligently, 
not  merely  in  a  routine  way,  should  seek  to  apprehend  the  elements  of 
the  problem,  to  visualize  the  reciprocal  relations  of  the  fragments,  to 
call  to  mind  the  opposing  forces,  and  correctly  to  estimate  his  power  to 
effect  or  control  the  position  of  the  fragments.  If  that  power  exists 
it  will  be  comparatively  easy  to  select  appropriate  means  to  obtain  the 
desired  result,  if  that  be  possible,  and  incidentally  to  form  a  correct 
judgment  as  to  the  merits  of  the  methods  offered  for  his  choice.  He 
will  find  that  in  not  a  few  cases  his  ability  to  control  one  of  the  fragments, 
especially  when  it  is  small  and  articular,  is  limited  or  even  nil,  but 
experience  will  tell  him  that  in  many  such  cases,  habitually  in  some 
classes  of  injury,  such  control  is  not  needed  to  obtain  as  satisfactory 
a  result  as  other  unchangeable  conditions  will  permit.  As  will  appear 
in  the  description  of  individual  forms  of  fracture  a  complete  anatomical 
restoration  of  form  may  be  impossible,  and  the  acceptance  of  deviations 
from  it,  sometimes  notable  ones,  may  be  compulsory.  The  attempt 
to  obtain  more  than  the  physical  conditions  permit  may  even  increase 
the  defects,  and  the  judicious  criterion  is  often  to  be  found  in  the 
ultimate  function  rather  than  in  form. 

Generally  speaking,  the  treatment  of  a  fracture  should  begin  when  the 
patient  is  first  seen,  but  by  this  it  is  not  meant  that  every  indication 
should  at  once  be  met  by  appropriate  measures ;  even  the  correction  of 
the  displacement,  the  "setting"  of  the  fracture,  and  the  immobilization 
of  the  fragments  may  have  to  be  left  undone  or  incomplete  because 
of  conflicting  and  dominating  conditions,  such  as  extreme  swelling, 
muscular  spasm,  or  associated  lesions.  A  delay  of  even  several  days  is 
usually,  in  respect  of  these  indications,  of  small  importance,  for  the 
preparatory  work  in  the  bone  and  soft  parts  goes  on  notwithstanding 
it,  and  when  finally  the  adjustment  is  made  the  condition  differs  but 
little  from  that  which  would  have  existed  had  it  been  made  at  the  first. 

An  important  indication  in  most  cases  is  to  prevent  additional  injury 
while  the  patient  is  being  taken  home  or  to  hospital.  The  danger  at  this 
(82) 


TREATMENT.  83 

time  is  that  by  incautious  handling,  disordered  movements,  or  injudicious 
attempts  to  use  an  injured  Hmb  a  simple  fracture  may  be  made  com- 
pound or  additional  laceration  caused.  This  risk  exists  especially  after 
fracture  of  the  leg  because  a  large  extent  of  the  surface  of  the  tibia  lies 
immediately  beneath  the  skin  and  the  end  of  a  fragment  can  easily 
be  forced  through  it.  The  surgeon  therefore  will  protect  the  limb  by  a 
temporary  splint,  when  such  protection  is  needed,  and  the  judicious 
la\Tnan  will  leave  the  patient  undisturbed  or  will  transport  him 
recumbent. 

If  the  fracture  is  one  which  necessitates  confinement  to  the  bed,  the 
bed  should  be  narrow  and  high,  and  the  mattress  firm.  A  long,  broad 
board  may  be  placed  beneath  the  latter  if  the  spring  mattress  is  soft. 
Specially  constructed  "  fracture-beds/'  some  of  which  are  very  ingen- 
iously arranged,  are  convenient,  but  not  at  all  essential.  A  water-bed 
or  air-bed  is  of  the  greatest  value  in  the  treatment  of  fractures  of  the 
spine  in  minimizing  the  formation  and  duration  of  bed-sores. 

The  points  to  be  considered  and  the  indications  to  be  followed  by  the 
surgeon  called  to  treat  a  fracture  vary  greatly  in  different  cases  accord- 
ing to  the  bone  or  portion  of  bone  involved,  the  complications  that 
exist  or  are  to  be  feared,  and  the  age,  the  health,  the  habits,  and 
even  the  social  status  of  the  patient.  At  one  end  of  the  long  and 
varied  series  of  problems  which  present  themselves  he  has  only  to 
provide  the  simplest  means  to  protect  the  patient  from  additinal  in- 
jury or  pain  during  the  few  days  or  weeks  that  are  needed  for  repair; 
at  the  other  the  highest  resources  of  his  art  are  required  to  save  life 
or  limb  or  to  preserve  function.  On  the  one  hand,  the  fracture  may 
be  the  sole  thing  to  be  considered,  his  attention  must  be  unremittingly 
given  to  the  position  of  the  fragments  and  their  maintenance  in  proper 
relations,  and  his  skill  and  care  will  determine  the  character  of  the 
result ;  on  the  other,  his  best  endeavor  may  be  powerless  to  affect  the 
position  of  the  fragments  or  modify  the  result,  or  the  fracture,  as 
in  many  of  the  base  of  the  skull,  may  be  a  wholly  unimportant  and 
negligible  incident  beside  the  associated  lesion. 

The  indications  for  treatment  arise,  therefore,  in  varying  degrees 
from  the  fracture  itself,  the  associated  lesions,  and  the  immediate  or 
late  local  or  general  effects  upon  the  patient.  Occasionally  they  con- 
flict, and  the  surgeon  must  then  temporarily  disregard  some  or  he  must 
even  be  content  with  a  defective  local  result  because  an  attempt  to 
secure  a  better  one  would  involve  risks  disproportionate  to  the  advan- 
tage sought.  Those  directly  concerned  with  the  fracture  are  to  cor- 
rect displacement  of  the  fragments,  if  such  displacement  exists  an(l  if 
its  correction  is  possible  and  advisable,  and  to  oppose  by  appropriate 
means  the  action  of  those  forces  which  might  reproduce  it,  such  as 
muscular  action,  swelling,  and  gravity.  This  correction  of  the  dis- 
placement is  termed  the  ''reduction"  or  "setting"  of  the  fracture. 

Reduction. 

Not  every  fresh  fracture  is  accompanied  by  a  displacement  that  needs 
to  be  corrected ;  and   of  those  in  which  such  displacement  exists,  in 


84  FRACTURES. 

not  every  one  is  reduction  possible  or  advisable;  and  sometimes  when 
reduction  is  both  possible  and  advisable  circumstances  require  that  it 
should  be  delayed. 

Fractures  without  a  displacement  that  needs  to  be  corrected  are 
many  and  varied,  such  as  most  simple  fractures  of  the  cranium,  of  the 
scapula,  of  the  ribs,  the  ilium,  the  shaft  of  the  fibula  or  ulna  alone, 
and  many  of  the  metacarpal  and  metatarsal  bones. 

Reduction  is  said  to  be  impossible  (although  in  most  cases  the  better 
term  would  be  inadvisable)  when  the  opposing  conditions  are  such  that 
they  cannot  be  overcome  by  the  methods  ordinarily  in  use,  and  when 
more  efficient  ones  would  involve  overbalancing  disadvantages  or 
risks.  The  causes  of  this  condition  are  varied ;  among  them  may  be 
mentioned  the  interlocking  of  the  irregular  ends  of  the  main  frag- 
ments, the  interposition  of  soft  parts  or  small  fragments,  the  small  size 
and  inaccessible  position  of  a  fragment,  as  in  some  articular  fractures, 
and  in  fractures  that  are  not  entirely  fresh,  the  infiltration  and  thicken- 
ing of  the  neighboring  soft  parts.  When  the  fracture  is  of  the  shaft 
or  subcutaneous  end  of  a  long  bone  the  existence  and  character  of  the 
displacement  are  usually  recognizable,  but  when  one  of  the  principal 
fragments  is  a  part  of  the  articular  end  of  a  long  bone  and  is  thickly 
covered  by  muscle  or  masked  by  swelling,  not  only  the  character  but 
even  the  existence  of  the  displacement  may  be  in  doubt  and  remain  so 
until  after  repair  is  far  advanced,  unless  the  .r-rays  are  used.  In  such 
cases  an  exact  diagnosis  can  be  made  and  reduction  can  generally  be 
effected  by  the  aid  of  an  incision  which  exposes  the  seat  of  fracture, 
but  although  the  probability  that  such  an  operation  in  experienced  hands 
and  under  proper  precautions  would  be  followed  by  disaster  is  small, 
yet  the  evils  of  such  a  result,  if  it  should  follow,  are  usually  so  in  ex- 
cess of  those  resulting  from  the  persistence  of  the  displacement  that 
the  operation  until  of  late  years  has  been  rarely  undertaken  while  the 
injury  was  recent,  and  then  mainly  because  of  the  presence  of  some 
controlling  condition  or  danger,  such  as  pressure  upon  the  skin  or  pen- 
etration of  a  muscle  that  could  not  otherwise  be  removed.  Neverthe- 
less, displacements  unrelievable  by  manipulation  and  likely  to  involve 
serious  loss  of  function  if  not  corrected,  can  often  be  recognized,  and 
in  such  cases  reduction  by  open  operation  is  called  for.  They  are  gen- 
erally cases  in  which  the  limb  has  been  greatly  distorted  at  the  time  of 
the  accident,  so  that  the  sharp  end  of  a  fragment  has  been  driven  into 
an  adjoining  muscle  or  through  the  enveloping  fascia,  or  an  obliquely 
broken  fragment  has  been  forced  around  to  the  opposite  side  of  the 
other  from  which  it  has  been  broken,  or  after  fracture  involving  a 
joint.  The  first  form  is  not  uncommon  in  fractures  of  the  lower  end 
of  the  femur  or  in  the  neighborhood  of  thinly  covered  joints.  From 
the  admitted  propriety  of  operative  interference  in  such  cases  it  is  a 
long  step  to  similar  interference  in  all,  as  has  been  urged  ;  and  such 
generalization,  if  accepted,  would,  in  my  judgment,  lead  to  disasters 
far  more  serious  and  numerous  than  the  disadvantages  that  would  follow 
failure  to  reduce  the  displacements.    Ranzi^  reports  4  severe  infections 

1  Ranzi:  Arch,  filr  klin.  Chir.  vol.  Ixxx.,  pp.  567  and  843. 


TREATMENT.  85 

in  50  operations  and  protests  against  the  generalization  of  reduction  by 
operation;  Tuffier,  quoted  by  Bardenheuer,  3  in  22;  Korte,  2  in  4.  See 
also  Fritz  Konig^  for  a  thoughtful  study  of  the  conditions  justifying 
or  forbidding  operation,  and  a  valuable  paper  on  the  late  results  after 
fracture  of  the  femur  by  Ashhurst  and  Newell. - 

The  reasons  advanced  by  those  who  favor  reduction  bv  operation  and 
mechanical  fixation  by  suture  or  pins  as  a  general  practice  are  that  bv 
this  means  alone  can  complete  reduction  be  made  and  maintained  and 
failure  of  union  certainly  prevented.  To  this  the  reply  may  be  made 
that  failure  of  union  is  rare,  and  that  in  most  cases  it  is  due  to  a  general 
cause  and  not  to  a  local  one  which  can  be  removed  bv  operation,  and 
that  when  such  local  cause  exists  the  fact  is  usually  apparent  and  is 
then  a  proper  reason  for  operating.  Further,  that  even  if  exact  reduc- 
tion is  made  by  operation  the  use  of  sutures  or  pins  to  maintain  it  is 
not  only  ineffectual,  but  is  also  in  itself  objectionable,  because  it  may 
cause  delay  and  even  failure  of  union  by  exaggerating  the  rarefactive 
process  which  precedes  repair,  and  delaying  or  ]ireventing  the  productive 
osteitis  which  alone  can  complete  it.  Lane's  plates  applied  with  scrupu- 
lous care  appear  to  be  largely  free  from  the  objection.  The  wire  suture 
breaks  or  becomes  loose,  pins  loosen,  so  that  for  effective  support 
during  repair  we  must  still  depend  upon  the  same  external  means  that 
are  used  when  no  operation  is  done.  Irregularities  in  the  union  rarely 
cause  any  interference  with  function,  and  diminish  as  time  passes,  es- 
pecially in  the  young.  Kecent  observations  by  Konig^  have  shown 
most  remarkable  corrections  thus  effected,  within  three  or  four  years 
after  the  fracture,  of  displacements  which  would  have  been  thought  to 
ensure  conspicuous  deformity  and  disability,  and  these  have  been  con- 
firmed by  Kiimmell,^  who  presented  to  the  International  Surgical  Con- 
gress at  Brussels  a  series  of  photographs  showing  "  astonishing  "  res- 
torations to  normal  form  after  severe  joint-  and  shaft-fractures,  with 
notable  splintering  and  displacements.  Finally,  the  additional  injury 
to  the  periosteum,  which  is  apparently  inevitable  in  the  exposure  of  the 
bone  for  drilling,  delays  union  and  facilitates  later  displacement;  and 
the  injury  done  to  the  muscles,  if  the  knife  has  to  pass  through  them 
to  expose  the  bone,  is  liable,  perhaps  likely,  to  restrict  the  mobility  of 
the  corresponding  joint  through  cicatricial  change  in  the  muscle  or  its 
attachment  to  the  callus.  It  seems  to  me  clear  that  operation  should 
be  reserved  in  fractures  of  the  shaft  for  those  cases  in  which  it  is  clearly 
indicated  by  some  marked  and  otherwise  irreducible  dis})lacement,  and 
that  for  the  maintenance  of  reduction  thus  made  reliance  should  be, 
in  principle,  upon  external  support,  and  local  aid  should  be  used  only 
when  clearly  indicated.  Such  local  aid  should  not  be  a  metallic  suture 
crossing  the  line  of  fracture;  it  may  properly  be  a  silk  or  absorbable 
suture  when  not  much  strength  is  called  for,  or  a  Lane  plate  or  ])oue 
insert  when  more  strength  is  needed,  or  soft  iron  wire  wrapped  about  the 
overlapping  ends  of  an  oblique  fracture.    A  temporary  metallic  suture, 

1  Konig:  Arch.  f.  klin.  rhir.,  vol.  Ixxvi.,  p.  725. 

2  Ashhurst  and  Newell:  Annals  of  Surg.,   Nov.,   1908. 

3  Konig:  Arfh.  fiir  klin.  C'liir.,   1908,  vol.  Ixxxv.,  p.  187. 
«Kummell:  Ztlblatt,  fiir  Chir.,  1911,  p.  1453. 


g6  FRACTURES. 

with  long  ends  left  projecting  through  the  incision  and  maintained  for 
about  a  fortnight,  is  relatively  free  from  the  objection  of  causing  ex- 
cessive rarefaction,  and  so  also  is  a  temporary  metal  pin  or  Hawley's 
loop,  but  both  have  the  disadvantage  of  maintaining  an  open  wound. 
(See  also  p.  113.) 

In  articular  fractures  the  conditions  are  different:  the  displacement 
if  uncorrected  may  seriously  compromise  the  usefulness  of  the  joint, 
and  but  little  if  any  relief  is  to  be  expected  from  a  late  operation. 
If  anything  is  to  be  done  it  must  be  while  the  injury  is  still  recent. 
I  have  taken  this  course  in  a  considerable  number  of  cases,  and  with- 
out ill  result  in  any,  but  I  am  convinced  it  should  be  resorted  to  only 
after  thorough  study  of  the  conditions  and  careful  weighing  of  the 
probabilities.  The  risk  of  such  primary  interference  by  operation  is, 
I  think,  less  if  done  within  the  first  twenty-four  hours  or  after  the  lapse 
of  several  days  and  the  subsidence  of  the  reaction. 


Fig.  :_ 


Making  forcible  traction  in  fracture  of  tlie  femur. 


Other  conditions  which  make  exact  and  immediate  reduction  inad- 
visable or  even  impossible  are  comminution  of  the  spongy  portion  of  a 
bone,  crushing  of  the  same,  extreme  subfascial  swelling  of  the  broken 
limb,  muscular  spasm,  and  coincidert  injuries  or  other  conditions  which 
prevent  the  application  of  a  dressing  efficient  to  maintain  the  reduction 
when  effected.  In  comminution  of  the  end  of  a  bone  the  fragments 
are  commonly  so  shifted  and  crushed  that  anything  like  an  exact  read- 
justment, even  by  open  operation,  is  impossible.  Crushing  of  the 
spongy  tissue  is  seen  mainly  in  the  old,  at  the  upper  end  of  the 
femur  and  humerus,  at  the  lower  end  of  the  radius,  and  in  the  bodies 
of  the  vertebrae.  The  effect  of  this  crushing  is  the  same  as  the 
removal  of  a  piece  of  the  bone;  if  the  fragments   are  restored  to 


TREATMENT. 


87 


their  original  positions  a  gap  corresponding  to  the  amount  of  the 
crushing  is  created  between  them,  which,  if  the  position  is  maintained, 
must  be  filled  by  the  production  of  new  bone,  a  task  that  may  l)e 
beyond  the  power  of  the  organism,  and  failure  in  which  would  lead 
to  failure  of  union,  a  result  much  more  disabling  than  the  persistence 
of  the  deformity. 

Extreme  subfascial  swelling  of  an  injured  limb  shortens  it  and 
increases  its  transverse  diameter,  because  the  capacity  of  the  fascial 
sheath  is  greater  the  more  nearly  it  approaches  the  globular  form; 

Fig.  38. 


Making  furcihli'  tractinn  in  fracture  of  the  leg. 

consequently  forcible  elongation  of  the  limb  with  the  object  of  cor- 
recting the  shortening  diminishes  the  capacity  of  the  fascial  sheath 
and  increases  its  tension  and  the  pressure  u]>on  its  contents ;  this 
resistance  may  be  sufficient  to  maintain  the  shortening  against  any 
reasonable  effort  to  overcome  it,  or  to  endanger  the  vitality  of  the 
limb  by  interference  with  the  circulation.  It  is,  therefore,  necessary 
to  await  the  subsidence  of  the  swelling. 

Muscular  spasm,  excited  by  the  trauma  or  by  pain  or  the  fear  of 
pain,  acts  ]>owerfully  at  jfirst  to  fix  the  fragments  in  their  faulty 
positions  and  especially  to  produce  and  maintain  shortening  of  the 
limb.  It  usually  disappears  within  a  day  or  two,  and  can  be  tempo- 
rarily annulled  by  anaesthesia  or  a  full  dose  of  opium  or  by  deep  injec- 
tion at  the  fracture  of  J  to  1  grain  of  cocaine  in  weak  solution  (Qiienu). 

Associated  injuries  or  conditions  whic^h  prevent  or  delay  reduction 
may  be  general  or  local,  such  as  profound  shock  due  to  the  fracture 
or  to  other  injuries,  damage  to  the  main  vessels  of  the  limb  threaten- 
ing gangrene,  and  extensive  wounds  of  the  skin  wliicli  woukl  prevent 
the  use  of  dressings  to  maintain  reduetion. 

In  the  absence  of  any  of  tiiese  (;ontraindications  the  soonei-  the 
fracture  is  "set,"  the  sooner  the  fragments  are  brought  to  and  lixed 
in  the  positions  they  are  expected  to  keep  during  repair,  the  better; 


88  FRACTURES. 

for  although  the  preparatory  changes  in  the  bone  itself  require  several 
days,  and  in  places  even  weeks,  for  their  completion,  yet  the  accessory 
processes  in  the  soft  parts  begin  immediately,  and  it  is  desirable  that 
they  should  not  be  interrupted  or  undone  by  changes  of  place  and 
relations.  The  thickening  and  infiltration  of  the  parts  adjoining  the 
bone  which  appear  so  promptly  give  a  steady  increasing  fixity  to  the 
position  of  the  fragments,  and  it  is  desirable  that  that  position  should 
as  early  as  possible  be  made  the  permanent  and  final  one.  A  con- 
venient method  of  maintaining  firm  steady  traction  in  fracture  of  the 
leg  or  thigh  is  shown  in  Figs.  37  and  38,  the  traction  being  made  by 
the  weight  of  the  assistant's  body  rather  than  by  his  muscles.  An 
ansesthetic  is  often  desirable  and  sometimes  necessary,  not  only  for  the 
avoidance  of  pain,  bat  also  to  annul  the  opposition  of  the  muscles  and 
make  possible  minute  examination  by  palpation,  and  to  aid  the  correc- 
tion of  displacements. 

The  actual  reduction  or  setting  of  the  fracture  is  in  many  cases  a 
procedure  guided  only  by  general  ideas,  not  by  an  exact  and  detailed 
knowledge  of  the  peculiarities  of  the  displacement  to  be  overcome  or 
even  of  the  lines  of  fracture,  and  the  extent  to  which  the  effort  has 
been  successful  can  only  be  surmised,  not  positively  known.  Such  is 
notably  the  case  in  fracture  of  the  shaft  of  a  long  bone  thickly  covered 
with  muscle,  as  the  femur.  By  eye,  touch,  and  measurements  the 
surgeon  can  recognize  shortening,  angular,  rotatory,  and  perhaps  even 
lateral  displacement,  and  by  traction  and  pressure  he  can  straighten 
and  lengthen  the  limb,  but  he  cannot  know  whether  or  not  the  adjust- 
ment of  the  fragment  is  accurate  and  close.  The  same  is  measurably 
true  even  of  many  fractures  of  bones  that  are  more  or  less  subcuta- 
neous and  palpable  ;  or  if  palpation  shows  some  remaining  irregularity 
of  outline  the  best  effort  may  be  unavailing  to  correct  it.  This, 
however,  does  not  make  the  result  so  much  a  matter  of  chance  as  the 
statement  may  seem  to  indicate ;  the  main  factors  of  displacement  at 
the  different  points  are  known,  and  the  surgeon  is  safely  guided  by 
this  knowledge  in  his  choice  and  use  of  methods  to  make  and  main- 
tain reduction  and  of  the  attitude  and  support  given  to  the  limb  while 
the  fracture  is  healing,  and  is  justified  in  awaiting  the  outcome  with 
a  confidence  that  is  limited  only  by  knowledge  of  the  fact  that  in  a 
certain  proportion  of  cases,  fi)rtunately  small,  unknown  and  unknow- 
able factors  may  defeat  efforts  wisely  conceived  and  faithfully  ex- 
ecuted. The  ideal  is  the  complete  restoration  of  form  and  function, 
but  he  must  often  be  content  to  obtain,  or  even  to  seek,  much  less. 
These  more  or  less  necessary  limitations  will  be  mentioned  in  connec- 
tion with  the  results  of  the  individual  varieties  of  fracture.  A  suitable 
a;-ray  outfit  may  disclose  details  of  displacement  and  guide  the  eftorts 
of  the  sm"geon  to  make  reduction. 

Since  the  principal  causes  of  displacement  after  fracture  of  the  shaft 
of  a  long  bone  are  the  tonic  contraction  of  the  attached  muscles  and 
the  unsupported  weight  of  the  lower  segment  of  the  limb,  reduction 
is  commonly  effected  by  bringing  this  lower  segment  into  line  with 
the  upper  one  and  making  steady  traction  upon  it  in  the  direction  of 
its  long  axis,  the  different  joints  being  usually  held  in  partial  flexion 


TREATMENT.  89 

in  order  that  the  attached  muscles  on  either  side  may  be  correspond- 
ingly relaxed.  Note  must  be  taken,  in  fractures  at  certain  points,  of 
the  known  tendency  of  the  upper  segment  to  assume  a  certain  attitude 
because  of  the  unopposed  action  of  the  nuiscles  attached  to  it,  an  atti- 
tude which  is  often  bnt  faintly  indicated  by  the  form  of  the  limb  if 
the  fragment  is  short  and  thickly  covered  by  muscle.  Common  ex- 
amples are  furnished  by  fractures  of  the  upper  third  of  the  femur  and 
of  the  surgical  neck  of  the  humerus,  in  both  of  which  the  upper 
fragment  may  be  markedly  abducted,  flexed,  and  rotated  outward. 
The  surgeon  confidently  places  the  lower  segment  in  the  corresponding 
attitude,  even  if  he  cannot  detect  the  deviation  of  the  upper  one,  for 
he  knows  that  even  if  it  does  not  exist  the  upper  fragment  will  follow 
the  movement  he  gives  to  the  lower  one,  and  the  two  pieces  will  be 
in  line  when  he  makes  the  traction  designed  to  give  the  limb  its  proper 
length. 

While  traction  (and,  if  necessary,  rotation  of  the  lower  segment) 
is  made  the  surgeon  makes  lateral  pressure  to  correct  such  lateral  dis- 
placement as  may  remain,  and  seeks  to  discover  and  take  advantage 
of  such  peculiarities  of  the  line  of  fracture  as  may  aid  him  to  main- 
tain the  position  he  gives  the  fragments.  Thus,  in  a  transverse  frac- 
ture or  in  one  with  marked  irregularities  of  outline  the  opposing  ends 
may  be  so  engaged  with  each  other  that  the  lower  fragment  will  be 
held  in  place  and  kept  from  overriding,  notwithstanding  the  pull  of 
the  muscles.  If  there  is  only  an  angular  displacement,  as  in  partial, 
subperiosteal,  and  some  transverse  fractures,  traction  is  not  needed, 
and  the  surgeon  has  only  to  correct  the  deviation  by  lateral  pressure. 
In  the  partial  fractures  of  adolescence  this  sometimes  requires  con- 
siderable force,  but  usually  it  can  be  accomplished  by  the  hands  alone, 
the  thumbs  being  placed  against  the  angle  while  the  fingers  grasp  the 
limb  above  and  below  it. 

A  serious  obstacle  to  reduction  occasionally  arises  from  the  penetra- 
tion of  the  overlying  muscle  and  fascia  by  the  sharp  end  of  one  of  the 
fragments,  usually  the  upper  one.  This  occurs  most  frequently  in 
oblique  fracture  of  the  lower  third  of  the  femur,  and  can  there  be 
treated  most  effectively  by  flexing  the  hip  and  the  knee  to  a  right 
angle,  thus  drawing  the  relaxed  quadriceps  (which  is  the  muscle  com- 
monly penetrated)  downward  past  the  engaged  end  of  the  upper  frag- 
ment, and,  if  necessary,  completing  the  act  by  traction  at  the  knee. 
This  exemplifies  the  principles  of  treatment  in  all  cases:  relaxation 
of  the  muscle,  if  it  crosses  the  proximal  joint,  by  moving  the  limb  toward 
the  corresponding  side;  drawing  the  muscle  dow^nward  by  bending  the 
distal  joint  in  the  opposite  direction;  and  then  lifting  the  lower  segment 
of  the  limb  bodily  away  from  the  upper  fragment.  If  this  or  other 
appropriate  manipulations  fail,  the  fragment  must  be  exposed  by  an 
incision  and  freed  by  direct  means.  If  the  fragment  has  perforated  the 
skin  also  the  opening  should  be  at  once  enlarged  and  reduction  guided 
and  aided  through  it;  as  the  external  wound  exists,  nothing  is  lost  and 
much  may  be  gained  by  freely  using  it  for  reduction,  cleaning,  and 
drainage. 


90  FRACTURES. 

In  some  cases  of  fracture  at  the  border  of,  or  just  within,  the  ex- 
panded spongy  end  of  a  bone,  where  the  fragments  are  interlocked  or 
impacted,  as  in  some  Colles's  fractures  at  the  lower  end  of  the  radius  or 
in  supracondyloid  fracture  of  the  lower  end  of  the  humerus  in  children, 
it  is  advisable  to  increase  the  irregular  displacement  as  a  first  step,  and 
forcibly  to  press  the  epiphyseal  end  downward  away  from  the  shaft  so 
as  to  free  it,  and  then,  correcting  the  lateral  displacement  by  pressure, 
to  turn  the  fragment  into  line ;  and  sometimes  the  small  epiphyseal 
fragment  has  to  be  moved  forward  and  backward  forcibly  so  as  to  break 
up  the  fine  interlocking. 

Under  similar  circumstances  the  epiphyseal  fragment  can  sometimes 
be  brought  into  place  by  so  changing  the  attitude  at  the  corresponding 
joint  as  to  make  tense  a  portion  of  the  capsule  which  is  attached  to  it 
and  then  by  continuing  the  movement  *to  correct  the  displacement,  or 
by  making  direct  traction  upon  it  through  its  ligaments.  In  some 
injuries — e.  g.,  separation  of  the  upper  epiphysis  of  the  humerus  and 
Pott's  fracture  at  the  ankle — the  character  of  the  displacement  is  so 
constant  that  a  formula  of  treatment  is  based  upon  these  facts  ;  similar 
formulae  have  been  made  for  injuries  at  other  points,  as  the  elbow  and 
knee,  but  the  lesions  and  displacements  are  there  too  varied  to  make 
routine  treatment  safe.  At  the  shoulder  the  separated  epiphysis  is  in 
anterior  flexion  and  abduction  although  the  arm  hangs  by  the  side  ; 
on  raising  and  abducting  the  elbow  the  movement  of  the  already  flexed 
and  abducted  epiphysis  is  promptly  arrested  at  the  normal  limit  by  the 
posterior  portion  of  the  capsule,  and  then  the  lower  portion  of  the 
humerus  is  brought  into  line  with  it  by  continuing  its  movement  in  the 
same  direction,  and  thus  the  angular  displacement  is  corrected. 

Retention. 

The  objects  of  retention  are  to  prevent  displacement  of  the  frag- 
ments by  the  various  agents  that  are  competent  to  produce  it,  notably 
gravity  and  muscular  contraction,  to  protect  the  limb  from  external 
violence  during  the  progress  of  repair,  and  to  prevent  the  pain  that 
would  be  caused  by  movement  of  the  fragments.  The  relative  im- 
portance or  urgency  of  these  needs  varies  greatly  in  different  cases, 
and  this,  together  with  the  mechanical  conditions,  measurably  deter- 
mines the  choice  of  the  method  of  treatment.  Thus,  in  the  fracture 
of  a  single  long  bone,  such  as  the  femur,  where  the  weight  of  the 
limb  and  the  action  of  the  muscles  are  efficient  and  always  ready  to 
produce  displacement,  support  equivalent  to  that  destroyed  by  the 
injury  must  be  supplied  by  apparatus;  while  in  fractures  of  only  one 
of  two  or  more  parallel  bones,  as  of  the  fibula  or  of  a  rib,  or  in  those 
of  the  flat  or  small  spongy  bones,  or  of  an  apophysis  or  condyle,  only 
sucli  a  dressing  is  required  as  will  moderate  or  prevent  voluntary  or 
involuntary  contraction  of  attached  muscles. 

The  swelling  of  a  limb  which  so  promptly  follows  its  fracture  is  an 
element  of  much  importance  because  its  variations  affect  the  adjust- 
ment and  fit  of  most  dressings  and  because  its  appearance  after  the 


TREATMENT.  91 

application  of  a  dressing  that  envelops  a  limb  may  so  interfere  with  the 
circulation  as  to  cause  gangrene  of  the  limb  or  ischsemic  degeneration 
and  contracture  of  the  muscles.  Full  flexion  of  the  elbow  may  lead  in 
the  same  way  to  the  same  result.  Such  dressings  should  therefore  be 
used,  if  at  all,  with  much  caution  and  should  be  frequently  inspected, 
the  fingers  or  toes  being  left  exposed  for  the  purpose. 

The  possibility  of  dangerous  constriction  is  specially  to  be  borne  in 
mind  in  dressings  which  completely  and  closely  encircle  a  limb  and 
which  are  inelastic,  such  as  a  plaster-of-Paris  encasement  or  even  a 
muslin  roller-bandage  applied  directly  to  the  surface  without  an  inter- 
vening layer  of  cotton.  Such  a  dressing  snugly  applied  while  the 
injury  is  recent  will  ahnost  always  become  too  tight  and  will  have  to 
be  removed  in  a  few  hours  either  because  of  the  paiu  which  it  causes 
or  of  the  threatenino-  strano-ulation  of  the  tissues.  This  is  true  even 
when  the  injury  is  a  comparatively  slight  one.  I  have  seen  gangrene 
of  the  hand  and  forearm  follow  the  application  of  a  gypsum  dressing 
for  fracture  of  the  olecranon.  A  roller-bandage  may  be  placed  directly 
upon  the  limb  below  the  fracture  to  restrain  its  swelling,  but  should 
not  be  carried  as  high  as  the  fracture  beneath  the  splints,  except  very 
loosely ;  and  when  splints  are  used  they  should  be  broad  enough  to 
prevent  circular  constriction  by  the  bandage  which  binds  them  in  place. 
If  plaster  of  Paris  is  used  it  should  preferably  be  in  the  form  of 
moulded  splints,  not  complete  encasement,  or  at  least  in  a  form  which 
will  permit  the  dressing  to  be  loosened. 

It  is  a  good  rule  also  to  remove  a  permanent  dressing  after  ten  or 
twelve  days  in  order  to  detect  and  correct  any  displacement  that  may 
have  taken  place  under  it  and  to  tighten  or  renew  it  to  meet  the 
shrinking  of  the  limb. 

It  is  specially  important  that  the  possibility  of  constriction  by  the 
dressing  should  be  guarded  against  whenever  the  injury  is  such 
that  it  may  itself  cause  gangrene  of  the  limb.  A  limb  whose  vitality 
has  thus  been  put  in  doubt  by  the  injury  should  be  treated  for  the 
first  few  days  with  the  primary  object  of  favoring  the  impaired  cir- 
culation and  especially  of  avoiding  the  creation  of  any  additional  ob- 
stacle to  the  venous  flow,  and  this  not  only  for  the  advantage  of  the 
patient,  but  also  for  the  protection  of  the  surgeon  against  the  suspicion 
or  the  charge  that  his  dressings  may  have  caused  the  gangrene.  This 
disastrous  result  of  injury  is  a  fruitful  source  of  suits  for  malpractice, 
and  the  defence  that  it  was  due  to  the  injury  and  not  to  the  treatment 
is  usually  viewed  with  so- much  suspicion  that  the  surgeon  should  be 
watchful  from  the  beginning  of  the  case  that  the  real  cause  should  be 
clear.  The  gangrene  is  usually  of  the  moist  form  and  due  to  interference 
with  the  venous  flow,  and  this  interference  may  easily  and  rapidly  be 
raised  to  a  dangerous  degree  by  circular  constriction  at  e\'en  a  single 
point.    Elevation  of  the  limb  by  favoring  the  flow  diminishes  the  risk. 

Cases  differ  far  too  widely  in  severity  and  local  conditions  to  permit 

of  a  general  rule  of  practice  applicable  to  all.     Many,  in  which  the 

tendencey  to  displacement  is  slight  or  easily  controlled,  may  be  treated 

in  a  permanent  dressing  from  the  beginning,  one  which  gives  the  nec- 

7 


92  FRACTURES. 

essary  support  without  danger  of  constriction,  and  can  be  left  in  place 
(or  with  temporary  removals  for  inspection)  for  one,  two,  or  three  weeks. 
Others,  more  severe,  such  as  most  fractures  of  the  femur,  also  receive 
a  permanent  dressing  at  the  beginning  because  this  dressing  is  mainly 
applied  below  the  seat  of  fracture  and  does  not  expose  to  constriction 
by  swelling.  Others,  such  as  many  fractures  of  the  leg,  may  need 
a  temporary  dressing,  such  as  a  Volkmann  splint,  for  from  five  to 
ten  days,  unless  permanent  moidded  splints  that  can  be  loosened  are 
used. 

So,  too,  when  the  surface  of  the  limb  has  been  so  torn  or  bruised 
that  the  wounds  cannot  be  properly  treated  through  an  opening  made 
for  the  purpose  in  a  permanent  dressing,  and  when  damage  to  the 
deeper  parts  forbids  the  use  of  any  constriction  or  pressure.  Under 
such  circumstances  the  surgeon  must  be  content  to  make  such  dressings 
as  the  associated  injuries  require  and  to  leave  the  limb  simply  sup- 
ported upon  the  bed  by  pads  or  in  splints  loosely  applied  over  the 
other  dressings.  Although  the  use  of  these  temporary  dressings  may 
be  necessarily  prolonged  for  several  weeks,  it  will  be  convenient  and 
proper  to  describe  them  under  that  title. 

The  presence  of  large  blebs  is  sometimes  an  additional  reason  for 
delay,  although  they  usually  heal  promptly  under  a  protective  dress- 
ing after  puncture.  If  it  is  desired  to  leave  the  limb  as  undisturbed 
as  possible,  it  is  advisable  thoroughly  to  clean  and  disinfect  the  ad- 
joining skin,  cut  away  all  the  raised  epidermis,  cover  the  exposed  sur- 
face with  sterile  rubber  tissue  or  silver  foil,  and  apply  a  gauze  dressing. 

Temporary  and  Removable  Dressings. 

The  object  of  a  temporary  dressing  is  mainly  to  protect  the  patient 
against  pain  and  additional  injury  by  movement  of  the  fragments 
during  transport  to  his  home  or  hospital,  or  to  prevent  displacement 
by  the  unsupported  weight  of  the  lower  segment  of  the  limb  ;  it  is 
rarely  efficient  to  prevent  displacement  by  the  action  of  the  muscles 
when  the  character  of  the  fracture  is  such  that  such  displacement  is 
possible. 

Side  Splints.  These  are  usually  made  of  wood,  but  in  case  of  need 
many  other  materials  are  available,  such  as  card-board,  stitf  leather, 
iron,  zinc,  tin,  even  bundles  of  tightly-rolled  straw. 

The  wooden  splint  in  its  simplest  form  is  a  piece  of  soft  wood  of  a 
length  and  breadth  corresponding  to  those  of  the  injured  limb  and 
thick  enough  not  to  bend  under  firm  pressure.  A  thick  layer  of 
cotton  or  other  soft  material  should  be  bound  along  the  side  which  is 
to  rest  against  the  limb,  and  t;hould  be  reinforced  at  needed  points  in 
order  to  fill  depressions  of  the  surface  of  the  limb.  Projecting  points 
of  bone  should  be  protected  by  cotton  placed  around  them,  not  upon 
them.  While  an  assistant  makes  traction  upon  the  lower  segment  of 
the  limb  the  surgeon  places  the  splints,  one  on  each  side,  and  binds 
them  on  with  a  roller-bandage,  taking  care  that  the  turns  support  the 
limb  throughout  its  entire  length,  but  do  not  make  circular  compres- 
sion.    The   splints   should  be  long  enough  to  support  the  hand  and 


TREATMENT. 


93 


foot  respectively.     A  form  in  common  nospital  use  is  the  thin,  bass- 
wood  spHnt,  the  necessary  rigidity  being  obtained  by  binding  several 

together. 

Fig.  39. 


Petit's  fracture-box. 


The  carved  splints  sold  in  packages  of  assorted  sizes  have  few  if 
any  points  of  superiority  over  those  improvised  for  the  occasion,  for 
they  also  need  to  be  fitted  and  padded.     If  it  is  desired  to  have  a 


Fig.  40. 


Volkmann's  splint  for  leg. 


splint  that  more  nearly  follows  the  contour  of  the  liml>  an  excellent 
one  can  be  made  with  plaster  of  Paris  (see  below)  or  cardboard  or 
leather  softened  in  water,  and  similar  ones  can  also  be  used  witli  ad- 
vantage over  the  dressings  that  are  needed  for  associated  wounds  of  the 
skin  or  compound  fractures. 


94 


FRACTURES. 


Splints  of  wire  that  can  be  measurably  modelled  to  the  limb  are  con- 
venient; they  can  be  had  from  the  instrument  makers. 

The  fracture-box  (Fig.  39)  is  a  form  of  wooden  splint  once  much 
used  in  fractures  of  the  leg,  but  now  almost  wholly  discarded  for  the 
following : 

Volkmaim's  splint  (Fig.  40)  is  a  shallow  gutter  and  foot-piece,  made 
in  several  lengths,  and  fitted  with  a  movable  support,  by  which  the 
foot  can  be  raised  from  the  bed.  For  use  it  is  thickly  padded  with 
cotton,  and  the  leg  is  bound  in  it  with  a  roller-bandage.  Care  must 
be  taken  that  undue  pressure  is  not  made  on  the  skin  covering  the 
front  of  the  tibia  by  the  bandage  or  on  the  heel  or  the  tendo  Achillis ; 
the  latter  pressure  is  best  avoided  by  slinging  the  foot  by  means  of  a 
broad  strip  of  adhesive  plaster  extending  from  the  middle  of  the  calf, 
under  the  heel  and  along  the  sole,  to  the  top  of  the  foot-piece,  where 
it  is  made  fast  by  a  reversed  piece  attached  to  it  and  then  to  the  lower 
surface  of  the  metal. 

Gutters  of  galvanized  wire  or  tin  (Fig.  41)  are  much  used  for  frac- 
tures of  the  humerus  :  they  give  more  protection  than  short  splints 
because  they  include  the  forearm.  They  can  be  readily  made  from 
sheets  of  wire  gauze  by  taking  a  strip  of  suitable  size  and  cutting  it 
partly  through  at  the  angle,  and  tying  together  the  meshes  which  over- 
lap where  it  is  bent. 

When  it  is  desired  to  cover  the  limb  with  dressings  because  of  the 
presence  of  a  wound  of  the  skin  or  to  make  moderate  uniform  com- 
pression, or  while  waiting  to 
learn  the  effect  of  the  injury 
upon  the  vitality  of  the  skin  or 
the  limb,  a  convenient  method 
of  applying  them  so  that  they 
can  be  readily  and  painlessly 
removed  for  adjustment  or  in- 
spection is  in  the  form  of  the 
Scultetus  bandage,  a  dressing 
which  was  formerly  in  wide  use 
for  retention.  The  dressings 
are  cut  in  thick  strips  one-half 
longer  than  the  circumference 
of  the  limb  and  three  or  four 
inches  wide,  and  then  arranged 
upon  a  piece  of  muslin  a  little 
longer  than  the  part  to  be 
dressed  in  such  a  way  that  each  overlaps  its  adjoining  upper  one  by 
about  an  inch.  The  limb  is  then  placed  along  the  centre  of  the  band- 
ages and  each  end  of  each  of  the  latter,  beginning  with  the  lowest, 
turned  over  the  front  of  the  limb  until  it  is  entirely  enveloped;  lateral 
support  is  given  by  splints  rolled  into  the  sides  of  the  underlying  strip 
of  muslin  and  bomid  fast,  or  by  other  splints,  or  by  placing  the  limb  in 
a  Volkmann  splint  or  a  gutter.  The  front  and  sides  of  the  limb  can  then 
be  readily  exposed  by  turning  back  the  ends  of  the  pieces  of  dressing. 


Fig.  41. 


Wire  gutter  for  the  arm  and  forearm. 


TREATMENT. 


05 


Instead  of  lateral,  anterior  or  posterior  splints  may  be  used,  either 
that  they  may  be  combined  with  suspension  or  that  portions  of  the 
limb  may  be  more  conveniently  exposed  and  dressed.  Because  of 
the  importance  of  equally  distributing  the  pressure,  a  posterior  splint 


Fig.  42. 


Suspended  moulded  splint  for  fracture  of  leg  or  lower  part  of  femur. 


to  be  used  with  suspension  should  be  accurately  fitted  to  the  limb; 
consequently  the  moulded  splints  (plaster  of  Paris,  gutta-percha,  etc., 
see  below)  are  to  be  preferred.  When  they  are  sufficiently  rigid  the 
limb  can  be  suspended  by  two  or  three  bandages  passed  beneath  and 
attached  above  to  a  suitable  support. 

Fig.  43. 


Nathan  R.  Smith's  anterior  splint. 

Late  in  the  treatment  of  fracture  of  the  femur  one  of  the  forms  of 
hip-splints  may  be  conveniently  used. 

Anterior  suspended  splints  may  also  be  of  the  moulded  kind,  \\\i\\ 
included  metal  rings  or  loops  for  the  attachment  of  the  supporting 


96 


FRACTURES. 


cords,  or  some  modification  of  Nathan  R.  Smith's  anterior  sphnt 
specially  designed  for  the  treatment  of  fractures  of  the  femur.  This 
splint  (Fig.  43)  is  made  of  two  parallel  iron  rods,  joined  at  the  ends, 
and  by  two  or  three  intermediate  rods,  bent  slightly  at  the  knee  and 
sharply  upward  at  each  end  to  fit  the  foot  and  pelvis.  It  is  placed 
along  the  anterior  surface  of  the  limb,  which  is  attached  to  it  by  a 
roller  or  by  straps,  suspended  by  cords.  When  used,  it  should  be  less 
bent  than  as  shown  in  Fig.  43,  and  the  leg  horizontal.  Recently  (1916), 
with  some  modification  in  shape,  it  has  been  freely  employed  in  France 
in  gunshot  fractures  and  other  painful  wounds  of  the  legs  by  American 
surgeons  and  under  the  influence  of  their  example. 

In  the  Cabot  splint  (Fig.  44)  the  bars  are  on  the  level  of  the  posterior 
surface  of  the  leg  and  there  is  a  foot-piece  to  support  and  control  the 


Fig.  44. 


Modified  Cabot  splint  for  suspension  and  rotation  in  fracture  of  leg.     (Flint.) 

position  of  the  foot  and  to  facilitate  shifting  of  the  attitude  of  the  patient 
in  bed  when  the  limb  is  suspended  (Figs.  45,  46).  A  modification  by 
Prof.  Flint  (Figs.  47,  48)  adds  to  the  comfort  of  the  patient  and  has  a 
self-contained  traction  appliance.  The  short  splint  is  provided  with 
wheels  which  run  upon  the  long  rods.  The  lower  segment  of  the  leg  is 
attached  by  adhesive  plaster  to  the  foot-bars  and  traction  is  made  by  a 
cord  connecting  the  short  splint  with  a  ratchet  wheel  at  the  lower  end 
of  the  long  rods.  Elasticity  in  the  traction  is  supplied  by  an  interposed 
spring  shown  in  the  illustration.  Counter-extension  is  provided  by 
binding  the  upper  part  of  the  limb  to  the  long  rod.  Pressure  eft'ects 
may  be  opposed  by  suspension  of  the  foot,  as  shown.  When  only  moder- 
ate traction  is  needed  and  when  the  lower  segment  is  short,  instead  of 
adhesive  plaster  a  well-fitting  anklet  or  well-padded  bands  about  the 
foot  may  be  used.  The  Hodgen  splint  (see  below)  with  provision  for 
traction  as  shown  in  Fig.  49  meets  the  indications  in  like  manner 


TREATMENT. 


97 


and  equally  well.    Of  course,  when  thus  used  its  suspension  should  be 
vertical. 

Moulded  splints  are  constructed  of  any  material  that  can  be  made 
temporarily  soft  enough  accurately  to  take  the  shape  of  the  part  to 


Fig.  45. 


Suspension  and  rotation  of  the  leg. 


which  it  is  fitted  and  which  then  becomes  hard  enough  to  retain  the 
shape  thus  given  to  it.  The  materials  most  frequently  used  are  plaster 
of  Paris,  pasteboard,  leather,  felt,  and  gutta-percha. 


Fig.  46. 


Showing  action  of  rotating  mechanism  as  position  is  changed.      (Flint.) 

Pasteboard  is  used  by  softening  one  or  two  strips  of  suitable  size  by 
immersion  in  hot  water,  and  then  moulding  them  to  the  limb  by  binding 


98 


FRACTURES. 


them   on   snugly  with   a  roller-bandage.     Temporary  support  must 
usually  be  given  by  other  splints  until  the  pasteboard  has  become 


Fig.  47. 


Details  of  splint.     (Flint.) 
Fig.  4S. 


Cabot  splint  with  suspension  and  internal  traction.      (Flint.) 

hard  by  drying.  \Yhen  it  is  necessary  to  bend  the  pasteboard  at  a  sharp 
angle  cuts  should  be  made  in  it  in  suitable  directions  and  places  and  the 
overlapping  portions  stitched  together. 


mSATMEMT. 


99 


Leather  and  felt  are  prepared  in  the  same  manner.  Gutta-percha 
is  used  in  strips  one-sixteenth  to  one-eighth  inch  thick  and  is  softened 
by  immersion  in  hot  water.  The  stickiness  of  the  surface  can  be  miti- 
gated by  covering  it  with  muslin. 

Plaster-of-Paris  or  gypsum  splints  can  be  made  of  the  prepared 
bandages  or  of  some  loose-meshed  material  soaked  in  plaster  cream. 
If  the  prepared  bandages  are  used  they  should  be  thoroughly  wet  in 
the  usual  way,  squeezed  out,  and  then  rapidly  unrolled  back  and  forth 
to  make  a  splint  of  the  desired  dimensions.  From  eight  to  fifteen 
layers  are  required  to  give  the  needed  solidity.  Plaster  cream  is  pre- 
pared by  sifting  the  dry  plaster  into  water  and  then  spreading  the 
plaster  thus  moistened  upon  the  selected  material  previously  cut  to 

Fig.  49. 


Hodgen  splint  with  self-contained  traction  for  fracture  of  leg.     (Flint.) 

suitable  shape  and  wrung  out  in  water.  The  number  of  layers 
needed  will  depend  upon  the  thickness  of  the  material,  and  care  must 
be  taken  thoroughly  to  work  the  plaster  into  them.  The  use  of  hot 
water  or  the  addition  of  salt  or  zinc  oxide  to  the  water  will  hasten 
the  setting.  If  the  plaster  has  been  long  exposed  to  the  air  before 
use  it  should  be  dried  in  an  oven;  otherwise  the  setting  may  be  long 
delayed  or  even  fail.  Splints  thus  prepared  can  be  made  impervious 
to  water  by  varnishing  them  or  by  pouring  melted  paraffin  upon 
them.  A  strip  of  rubber  tissue  or  oiled-silk  carefully  packed  in  at 
the  exposed  point  will  protect  satisfactorily  for  several  days  from  the 
discharge  of  a  wound.  Weight  can  be  reduced,  while  preserving  the 
strength,  by  inserting  thin  strips  of  metal  or  wood  at  places  where 
the  splint  will  not  require  much  modelling  to  fit  the  limb,  v^plints  of 
this  kind  are  specially  useful  in  fractures  at  the  ankle,  wrist,  elbow 


100 


FRACTURES. 


Fig.  50. 


and  arm,  and  not  infrequently  such  a  temporary  splint  will  remain 
efficient  for  two  or  three  weeks.  For  fractures  of  the  leg  one  of  the 
splints  should  be  posterior  and  broad  enough  to  cover  one-third  of 
the  circumference  of  the  limb;  a  narrower  anterior  one  may  be  used 

with  it,  or  a  lateral  one  the  lower  end  of 
which  encircles  the  instep,  or  a  bilateral  one 
crossing  below  the  instep  like  a  stirrup. 
The  posterior  splint  should  pass  along  the 
sole  and  project  about  an  inch  beyond  the 
toes  so  as  to  take  the  weight  of  the  bed- 
clothing.  They  must  be  snugly  moulded  to 
the  limb  with  a  roller  bandage,  and  the  de- 
sired position  of  the  fragments  maintained 
by  the  hands  or  a  suitable  support  until  the 
plaster  shall  have  set. 

If  for  any  reason  a  posterior  splint  cannot 
be  used,  a  strong  broad  anterior  one  may  be 
substituted,  and  if  suspension  is  desired  the 
inclusion  within  it  of  a  stout  wire  bent  into 
loops  at  several  points  will  facilitate  it  (Fig. 
42). 

A  form  of  bilateral  moulded  splint  which 
stocking  or  bivalve  plaster  splint,  j    j^^^^^    ^^^^^^^  convenient   iu    fractures    of 

the  leg  as  a  substitute  for  the  Volkmann  splint  during  the  first  week, 
and,  l^ecause  of  the  ease  with  which  it  can  be  removed,  even  for  the 
complete  encasement  in  plaster  of  Paris  which  usually  follows,  is  the 
following  :  Two  pieces  of  muslin  are  cut  to  the  shape  shown  in  Fig.  50, 
and  of  a  size  to  fit  the  limb,  and  stitched  together  along  the  median 
line.  Then  twelve  or  fifteen  pieces  of  crinoline,  or  three  or  four  of  can- 
ton-flannel, each  a  little  smaller  than  a  lateral  half  of  the  first,  are 
soaked  in  plaster  cream  and  laid  in  each  half  of  the  first  between  its 
two  lavers,  and  the  whole  then  bound  smoothly  to  the  limb  with  a 
roller-bandage.  Swelling  of  the  limb  is  met  by  loosening  the  band- 
age, and  inspection  is  easy  by  turning  down  either  lateral  half,  the 
line  of  stitching  acting  as  a  hinge.  The  additional  trouble  entailed  in 
its  preparation,  as  compared  with  the  Volkmann  splint  and  later  encase- 
ment in  plaster,  is  offset  by  the  greater  security  and  ease  with  which  the 
patient  can  be  moved  during  the  first  week,  and  the  ease  with  wliich 
the  dressing  can  be  removed  and  the  seat  of  fracture  inspected  so  long 
as  intercurrent  displacement  is  possible  and  corrigible- 
Suspension  and  Elevation. 

It  has  long  been  known  that  suspension  of  a  broken  limb  adds  greatly 
to  the  comfort  of  the  patient  when  he  is  confined  to  bed,  and  that  its 
elevation  in  compound  fractm-e  reduces  the  reaction,  aids  the  control 
of  infection  and  hastens  recovery;  but  adequate  appreciation  thereof 
has  been  far  from  general.  The  enormous  experience  in  severe  and 
severely  infected  compound  fractiu-es  of  the  present  (1916)  war  has 
brought  about  a  much  wider  appreciation  of  the  fact  and  will,  I  hope, 


TREATMENT. 


101 


lead  to  more  general  use  of  the  method.  Some  of  the  details  as  used  in 
fractures  of  the  leg  have  been  described  above,  those  for  use  in  fracture 
of  the  thigh  in  the  following  section. 

Overhead  support  can  be  provided  simply  and  satisfactorily  in  many 
cases  by  the  readily  made  frame  shown  in  Fig.  61),  but  a  more  elaborate 
structure  permitting  wider  and  multiple  adjustments  may  be  needed. 
Such  is  the  four-poster  bedstead  described  by  Prof.  Flint"^  (Fig.  51) 
which  might  well  be  made  part  of  a  standard  hospital  equipment, 
or  upright  wooden  frames  attached  to  the  head  and  foot  of  a  bed  and 
bearing  adjustable  longitudinal  and  transverse  bars.     In  Dr.  Joseph 

Fig.  51. 


Suspension  and  extension:  fracture  of  humerus.     (Flint.) 

Blake's  hospital  at  Ris  Orangis  near  Paris  I  saw  in  use  a  small  two- 
wheeled  trolley  running  on  an  iron  rod  underhung  from  an  overhead 
support  and  carrying  the  weight  of  the  limb ;  it  gave  additional  freedom 
of  motion  (see  also  Fig.  57). 

Traction  or  support  is  conveniently  attached  to  the  limb  by  strips 
of  adhesive  plaster,  as  in  Buck's  extension;  Dr.  Blake  used  as  an 
occasional  substitute  strips  of  muslin  fastened  to  the  skin  by  a  solution 
of  A  enetian  turpentine  and  resin  in  alcohol ;-  at  the  American  Ambulance 
at  Neuilly  painter's  glue  was  used.  Broad  support  of  the  limb,  when 
needed,  is  given  by  a  muslin  hammock  or  broad  band,  its  sides  held 
apart  by  spreaders,  or  by  a  metal  frame  as  in  Hodgen's  splint.     Dr. 

1  Flint:  Annals  of  Surg.,  June,   1916,  p.  644. 

2  Resin,  50  grams;  alcohol,  90 per  cent.,  50  c.c;  Venetian  turpentine,  1  gram;  benzine, 
10  per  cent. 


102 


FRACTURES. 


Flint  inserts  a  helical  spring  in  every  line  of  support  or  traction  to  dim- 
inish jar.  In  fracture  of  the  humerus  the  point  of  support  of  the  forearm 
can  be  changed  as  shown  in  Fig.  51  so  as  to  alter  the  angle  of  the  elbow; 
and  the  introduction  of  a  roll  which  the  fingers  can  grasp  at  will  favors 
the  maintenance  of  their  mobility. 


Fig.  52. 


Suspension  and  traction :  fracture  of  humerus.     (Flint.) 

Fig.  53. 


Fracture  of  leg  and  humerus.     (Fijnt.) 


This  method  of  suspension  not  only  makes  dressing  of  a  compound 
fracture  easy  but  also  tends  to  keep  the  proximal  joint  and  its  muscles 
in  normal  condition. 


TREATMENT.  103 

Permanent  or  Final  Dressings. 

The  dressings  included  under  this  title  are  those  designed  to  main- 
tain the  fragments  in  the  relative  positions  given  them  until  union  is 
complete  or,  at  least,  far  advanced.  They  are  expected  to  give  the  pro- 
tection and  quiet  of  the  temporary  dressings,  and  in  addition  to  oppose, 
with  as  much  efficiency  as  possible,  shortening  of  the  limb  or  angular 
displacement  by  muscular  contraction  or  gravity.  As  has  been  said, 
the  temporary  dressings  may  sometimes  be  used  equally  well  for  the 
same  purpose,  and  some  of  the  permanent  dressings,  especially  those 
making  continuous  traction,  may  be  used  from  the  beginning.  A 
rule  of  practice  which  will  save  the  surgeon  an  occasional  and  very 
disagreeable  surprise  and  disappointment  should  be  to  examine  about 
the  end  of  the  second  week,  and  again  later  if  the  fragments  are  still 
movable,  every  fracture  that  has  been  covered  by  the  dressing  in  order 
to  detect  and  correct  such  displacement  as  may  have  occurred  beneath 
it.  This  applies  especially  to  fractures  of  the  shaft  of  the  long  bones 
and  to  some  articular  fractures  in  which  displacement  is  easy. 

Complete  encasement  in  plaster  of  Paris,  occasionally  advisable, 
if  carefully  watched,  even  as  a  primary  dressing,  is  most  usefvil  and 
efficient  when  applied  after  the  swelling  has  subsided,  and  at  still 
later  stages  in  cases  in  which  continuous  traction  has  been  used  until 
union  has  become  well  advanced.  Its  mode  of  application  is  as  fol- 
lows :  The  limb  is  raised  by  one  or  two  assistants  who  make  steady 
traction  upon  it  in  order  to  keep  it  straight  and  of  full  length,  the  sur- 
geon wraps  it  in  a  thin  layer  of  cotton  batting,  preferably  prepared  in 
three-inch  rollers,  and  then  applies  the  plaster  roller-bandages,  thor- 
oughly wetted  and  wrung  out  in  hot  water,  from  below  upward.  The 
turns  of  the  first  layer  should  be  drawn  just  tight  enough  to  keep  their 
place,  and  the  subsequent  turns  simply  rolled  over  the  first  without 
increasing  the  pressure,  taking  care  to  model  the  dressings  accurately 
to  the  prominences  and  depressions  of  the  limb.  When  the  di'essing 
is  complete  the  limb  is  lowered  to  rest,  and  proper  support  given  it 
until  the  plaster  is  hardened.  Lightness  and  facility  of  removal  can 
be  gained  by  incorporating  one  or  two  suitably  placed  plaster  splints  in 
the  dressing,  and  using  only  enough  circular  turns  to  keep  these  si)]iiits 
in  place.  The  dressing  should  extend  far  enough  above  and  l)cl()w  the 
fracture  to  rest  against  such  prominences  of  the  skeleton  or  muscles  as 
may  be  present  and  will  act,  after  the  plaster  shall  have  set,  to  prevent 
movement  of  the  limb  within  its  case.  When  such  fixed  points  do  not 
exist,  as  at  the  shoulder  and  hip,  other  means  to  prevent  shortening 
must  be  used,  usually  some  form  of  traction.  The  uj)per  and  lower 
ends  should  be  so  placed  that  their  edges  will  not  make  irritating 
pressure  directly  against  a  diverging  surface  :  thus,  for  the  forearm  it 
should  stop  well  short  of  the  flexure  of  the  elbow  or  should  pass  a 
short  distance  up  the  arm  ;  at  the  ankle  it  should  stop  siiort  of  or  pass 
well  forward  on  the  dorsum  of  the  foot;  on  tiie  inner  side  of  the  thigh 
it  should  not  reach  the  perineum. 

The  fingers  or  toes  should  always  be  left  uncovered  and  should  be 
repeatedly  inspected  during  the  first  two  or  three  days  in  order  to  detect 
anv  interference  with  the  circulation. 


104 


FRACTURES. 


In  the  lack  of  plaster  rollers  the  dressmg  can  be  made  of  any  coarse 
material  cut  in  suitable  strips  and  soaked  in  plaster  cream. 

If  it  is  desired  to  have  a  small  portion  of  the  limb  exposed,  as  for 
the  dressing  of  a  wound,  a  fenestra  can  be  cut,  and  its  edges  protected 
with  adhesive  plaster,  rubber  tissue,  or  oiled  silk.  If  a  larger  opening 
is  required,  the  splint  must  be  reinforced  by  a  plaster  splint  along  the 
part  that  remains,  or  by  one  or  two  curved  iron  bands  incorporated  in 
the  dressing  or,  better,  fastened  to  it  by  additional  turns  of  a  plaster 
roller  after  the  main  portion  of  the  dressing  has  hardened.  ThcvSe  are 
termed  "fenestrated"  or,  if  the  opening  includes  the  entire  circumfer- 
ence, "interrupted"  splints  (Fig.  54). 

Ochsner  recommends  very  highly  a  means  devised  by  Croux  for  the 
protection  of  the  splint  against  the  discharges  in  compound  fractures. 

Fig.  54. 


Fenestrated  plaster  dressing. 


It  consists  of  a  thick  solution  of  India-rubber  in  chloroform  mixed 
with  small  pieces  of  lambs'  wool ;  this  is  poured  in  between  the  splint 
and  the  limb  around  the  opening. 

Similar  dressings  can  be  made  with  silicate  of  soda  or  potash,  starch, 
dextrin,  or  glue.  The  silicate  and  dextrin  are  used  by  thoroughly  satu- 
rating roller-bandages  with  the  material  and  applying  them  in  the  same 
manner  as  plaster  bandages.  They  do  not  dry  so  rapidly  as  plaster, 
but  are  lio-hter  and  cleaner  and  not  so  liable  to  crumble  at  the  edges. 
Silicate  is  frequently  used  for  dressings  of  the  hand  and  forearm. 
■  The  edges  of  both  silicate  and  plaster  dressings  can  be  advantageously 
protected  against  crumbling  by  covering  them  with  adhesive  plaster. 

The  removal  of  one  of  these  dressings  is  a  tedious  and  troublesome 
task  ;  it  can  best  be  done  by  cutting  lengthwise  with  a  short,  stout- 
bladed  knife,  aided  in  the  case  of  plaster  by  moistening  the  dressing 
along  the  line  of  the  division.  The  diminished  resistance  to  the  knife 
gives  warning  of  the  proxiinity  of  the  skin,  and  the  deepest  layer  and 
the  luiderlying  cotton  should  be  cut  with  strong  bandage  scissors.  The 
principal  difficulty  is  in  turning  re-entrant  angles,  as  at  the  front  of  the 
ankle  or  elbow.  After  the  division  has  been  completed  the  sides  can  be 
forcibly  drawn  back  and  the  limb  lifted  out. 

In  cases  in  which  the  absence  of  firm  points  of  support  makes  a 
fixed  dressing  inefficient  effectually  to  o])pose  the  contraction  of  the 


TREATMENT. 


105 


muscles,  as  in  most  fractures  of  the  thigh  and  many  of  the  humerus, 
permanent  moderate  traction  is  employed  to  tire  the  muscles  and 
obtain  and  maintain  the  desired  length  of  the  limb.  For  this  piiriiose 
the  partially  nnsujiported  weight  of  one  segment  of  the  limb  may  be 
utilized  or  a  weight  attached  to  the  lower  segment. 

Traction  by  Weight  and  Pulley,  or  Elastic  Traction.  This  method  is 
employed  almost  exclusively  in  the  treatment  of  fractures  of  the 
thigh.  Methods  of  treatment  by  continuous  traction  have  long  been 
in  use,  but  the  efficiency  and  comfort  which  now  make  the  metliod  so 

Fig.  55. 


V  V.  V   V 

/  /  /  / 


Adhesive  plaster  and  "spreader  "  for  Buck's  extension. 

popular  date  from  the  introduction  about  the  year  1850  by  the  Ameri- 
can surgeons  Sargent,  Josiah  Crosby,  and  Gurdon  Buck  of  the  use  of 
adhesive  plaster  to  attach  the  weight  or  screw  to  the  limb.  Previously 
the  attachment  was  by  bandages  about  the  foot  and  ankle,  and  the 
pain  and  damage  to  the  skin  occasioned  thereby  were  such  that  efficient 
traction  could  not  be  maintained. 

"Buck's  Extension."  (As  for  a  fracture  of  the  thigh.)  Two  strips 
of  stout  adhesive  plaster,  each  four  inches  wide  and  long  enough  to 
reach  from  well  above  the  knee  to  a  little  beyond  the  sole,  are  n- tched 
on  each  side  at  the  junction  of  the  lower  and  middle  thirds  for  one- 
third  their  width,  and  the  sides  turned  in,  as  shown  in  Fig.  55,  so  as 
completely  to  cover  the  adhesive  surface  of  that  portion.  The  sides 
of  the  remaining  portion  are  obliquely  notched  at  several  points.  A 
piece  of  wood,  5X3  inches,  with  a  central  hole,  is  then  covered  with 
adhesive  plaster  folded  beyond  the  ends,  as  shown  in  Fig.  55. 

A  third  piece  of  adhesive  plaster  a  yard  long  and  2  inches  wide  is 
cut  in  two  and  the  halves  fastened  together  end  to  end  by  facing  their 
terminal  four  or  five  inches;  it  is  attached  to  the  back  of  the  calf,  and 
brought  along  and  well  beyond  the  sole  of  the  foot;  a  roller-bandage 
is  applied  to  the  foot  and  lower  third  of  the  leg,  the  first  two  stnps 
of  plaster  placed  one  on  each  side  above  it  so  that  their  folded  por- 
tions extend  below  the  ankle,  and  the  roller  carried  over  them.  Unless 
the  fracture  is  too  low  the  roller  and  strips  of  plaster  should  be  car- 
ried well  above  the  knee.  The  ends  of  the  plaster  on  the  wooden 
"spreader"  are  then  attached  by  pins  or  clamps  to  the  free  ends  of  the 
lateral  plasters  so  that  the  "spreader"  lies  squarely  across  the  sole 
a  few  inches  below  it.  A  cord  is  then  passed  through  the  hole  in  the 
"spreader"  and  secured  by  a  knot. 

A  Volkmann's  sliding-rest  (Fig.  5())  is  then  placccl  under  the  leg, 
the  foot  lightly  swung   from   it  by  carrying  tiie  free  end  of  the  third 


106 


FRACTURES. 


strip  of  plaster  over  its  top  and  sticking  it  to  its  lower  surface,  and  the 
leg  secured  to  it  by  a  roller.  The  cord  is  then  carried  over  a  pulley 
at  the  foot  of  the  bed,  and  a  weight  of  from  ten  to  twenty  pounds 
attached.  Counter- extension  is  made  by  raising  the  foot  of  the  bed 
about  four  inches.  Coaptation  splints  about  a  foot  long  are  bound 
about  the  thigh  to  give  lateral  support,  or  a  molded  plaster  gutter  is 
used,  covering  the  posterior  half  of  the  thigh  from  the  gluteal  fold  to 
the  knee. 

Fig.  56. 


Volkmann's  sliding-rest  for  fractures  of  the  thigh. 

Suspension  with  the  aid  of  a  Cabot  splint  (Fig.  57)  answers  the 
purpose  even  better.  In  the  use  of  either  the  effort  should  be  made  to 
keep  the  knee  slightly  flexed. 

Steinmann^  made  traction  by  attaching  the  weight  to  two  nails  driven 
into  the  condyles  of  the  femur,  one  on  each  side.  Experience  in  its  use 
by  a  considerable  number  of  surgeons  has  gained  for  it  an  accepted  place 
as  a  proper  method  in  exceptional  cases,  although  it  involves  a  definite 
risk  of  leading  to  suppuration  and  even  fatal  sepsis.-  A  valuable  modi- 
fication is  the  substitution  for  the  two  nails  of  a  single  rod  transfixing 
the  condyles;  the  traction  is  conveniently  made  with  the  hinged 
instrument  showTi  in  Fig.  58,  in  the  upper  ends  of  which  the  ends  of  the 
nail  are  engaged. 

Hodgen's  suspended  spUnt  (Fig.  59)  is  a  modification  which  gives 
more  freedom  of  motion  and  consequently  more  comfort  to  the  patient. 

1  Steinmann:  Ztlblatt.   fur  Chir..    1907,   p.   938. 
s  Schwartz:  Ztlblatt.  flir  Chir.,  1909,  p.  1399. 


TREATMENT. 
Fig.  57. 


107 


Cabot  splint  used  with  Buck's  extension.     (Flint.) 

Fig.  58. 


For  traction  with  a  transfixing  pin. 

It  consists  of  two  parallel  iron  bars,  slightly  bent  at  the  point  corre- 
sponding to  the  knee  and  connected  at  the  lower  end  by  a  straight  bar 
and  at  the  upper  end  by  a  curved  one.  The  leg  and  thigh  are  placed 
between  these  bars  and  suspended  from  them  V)y  half  a  dozen  bands, 
and  the  ends  of  the  lateral  pieces  of  plaster  are  attached  to  the  lower 
cross-bar,  care  being  taken  that  they  do  not  press  again.st  the  malleoli, 
or  by  the  cord  of  the  spreader  of  Buck's  extension.  Then  the  limb  is 
raised  from  the  bed  by  a  cord,  as  shown  in  the  figure,  which  should  be 
attached  to  a  support  at  least  four  feet  (better  more)  above  the  l)ed  and 
so  placed  that  the  cord  is  inclined  fifteen  to  thirty  degrees  from  the 
vertical,  and  shall  thus  tend  constantly  to  draw  the  leg  downward  ; 
this  furnishes  the  traction,  and  by  moving  the  point  of  support  to  tiie 
8 


108 


FRACTURES. 


outer  side  the  position  of  abduction  of  the  thigh,  which  is  usually  desir- 
able, can  be  readily  obtained. 

Combined  Suspension  and  Traction  (Fig.  60) .  During  the  last  few  years 
I  have  used  a  combination  of  susyension  by  Hodgen's  splint  and  traction 
by  Buck's  extension,  which  has  given  much  satisfaction;  the  patients 

Fig.  59. 


Hodgen's  suspended  splint. 


are  much  more  comfortable  than  with  Buck's  alone,  and  the  traction  is 
more  efficient  and  regular  than  with  the  Hodgen.  Its  application  is 
sho^^'n  in  Fig.  60.  The  Buck's  extension  is  applied  in  the  usual  way,  and 
the  Hodgen  splint  adjusted  with  vertical  (not  oblique)  support.  The 
pulley  over  which  the  Buck's  cord  passes  should  be  at  least  twelve  to 
eighteen  inches  distant  from  the  patient's  foot  so  that  lateral  shifts  of  his 
position  shall  not  greatly  change  the  line  of  traction.  This  can  be  easily 
effected,  when  necessary,  by  so  binding  the  rod  which  carries  the  pulley 
to  the  bed  in  such  a  way  that  the  pulley  stands  well  out  beyond  the  foot 
of  the  bed.  Besides  the  greater  comfort  of  the  patient,  this  has  the  ad- 
vantage of  readily  giving  the  flexion  and  abduction  needed  in  high  frac- 
tures of  the  femur,  and  of  making  coaptation  pressure  upon  the  ends  of 
the  fragments  by  means  of  the  supporting  bands.  Other  advantages  are 
that  it  keeps  the  knee  slightly  flexed,  a  position  preferable  to  full  exten- 
sion, and,  by  the  elimination  of  the  friction  of  the  limb  upon  the  bed, 
requires  less  forcible  traction. 

If,  for  any  reason,  the  adhesive  plaster  cannot  be  applied  to  the  leg 
and  thigh,  it  may  be  attached  to  the  lower  part  of  the  thigh  alone  if 
the  fracture  is  rot  below  the  middle  of  the  femur;  or  a  long  towel 
folded  to  a  breadth  of  three  or  four  inches  may  be  placed  with  its  center 


TREATMENT. 


109 


on  the  front  of  the  thigh  just  above  the  knee,  and  its  sides  crossing 
behind  the  knee  and  brought  down  beside  the  leg ;  the  cord  of  the 
weight  is  then  attached  to  its  ends  by  an  intermediate  loop.  Either  of 
these  devices  may  also  be  used  if  it  is  desired  to  make  the  traction 
directly  in  the  line  of  the  femur  while  the  knee  is  flexed  more  than 
usual ;  but  whenever  the  hip  has  to  be  so  far  flexed  that  the  traction 
must  also  support  a  large  part  of  the  weight  of  the  limb,  as  in  sub- 
trochanteric fracture,  it  is  advisable  to  use  the  Hodgen  splint  alone,  as 
in  it  the  pull  is  distributed  more  widely  over  the  limb. 

Fig.  60. 


Combined  traction  and  suspension  in  fracture  of  the  femur. 

The  same  method  of  traction  is  sometimes  used  in  fractures  of  the 
thigh  in  connection  with  a  long  side  splint,  either  with  a  weight  and 
pulley  or  with  an  elastic  cord  on  the  side  of  the  splint  (Fig.  ()1),  and 
also  wath  one  of  the  forms  of  hip-splints,  but  it  is  far  less  efficient,  and 
its  use  should  be  restricted  to  temporary  conditions,  such  as  transport. 

Vertical  suspension,  for  fractures  of  the  thigh  in  infants  and  for  some 
fractures  of  the  arm,  can  be  obtained  in  Hkc  manner  l)y  tlic  use  of  the 
plaster  strips  and  a  cord  carried  to  a  ])oint  of  support  directly  a.l)o\e 
the  bed.     (See  Chapter  XXIII.) 


no 


FRACTURES. 


In  the  double  inclined  plane  (Fig.  62)  traction  is  made  by  the  weight 
of  the  upper  segment  of  the  thigh  and  pelvis.  It  consists  of  two  pos- 
terior splints,  for  the  leg  and  thigh  respectively,  hinged  at  the  knee  and 
kept  at  the  desired  angle  by  a  plank  upon  which  they  rest  and  to  which 


Fig.  61. 
Double  pulley 


Ind. -rubber  accumulator 
Long  side  splint  with  traction. 

Fig.  62. 


Esmarch's  double  inclined  plane. 

Fig.  63. 


Bardenheuer's  lateral  and  longitudinal  traction. 


the  upper  end  of  the  short  femoral  splint  is  hinged.  As  shown  in  the 
figure  the  femoral  spHnt  is  too  long;  it  must  be  so  short  that  the  upper 
part  of  the  thigh  is  wholly  unsupported  by  it,  and  the  mattress  must 
be  so  soft  that  the  pelvis  can  sink  into  it,  for  it  is  by  this  sinking  of 
the  pelvis  that  the  upper  fragment  of  the  broken  thigh  is  drawn  away 


TREATMENT.  Ill 

from  the  lower  one.  It  cannot  be  depended  upon  to  crive  a  good  result 
in  respect  of  shortening,  but  it  is  very  convenient  iu  some  compound 
fractures. 

While  efficient  traction  may  usually  be  confidently  depended  upon  to 
correct  not  only  overriding  but  also  lateral  and  angular  displacements, 
other  measures  may  be  needed  to  correct  or  prevent  these  latter  or 
rotatory  displacement.  In  the  femur  outward  rotation  of  the  upper 
fragment  can  be  prevented  by  a  sand-bag  placed  behind  the  great 
trochanter,  and  lateral  or  angular  displacement  opposed  by  correspond- 
ing lateral  traction,  made  either  by  the  upper  supporting  bands  in  a 
suspending  apparatus,  or  by  a  separate  weight  and  pulley  acting  trans- 
versely. The  latter  device  has  long  been  employed  and  recommended 
by  Bardenheuer  not  only  in  fractures  of  the  femur,  but  also  in  those  of 
other  limbs  and  even  the  fingers,  and  has  been  developed  by  him  to  an 
extreme  complexity. 

Constant  care  and  watchfulness  are  needed  to  detect  and  correct  dis- 
placements that  may  arise  in  the  course  of  treatment  through  the  action 
i>f  various  forces,  notably  gravity,  and  it  is  only  by  such  watchfulness 
that  grievous  disappointment  can  be  avoided. 

It  is,  unfortunately,  a  fact  that  the  successful  use  of  any  method  of 
traction  depends  upon  the  ability  of  the  surgeon  rightly  to  apprehend 
such  special  mechanical  problems  as  may  exist  in  the  given  case  and  to 
adjust  the  devices  to  their  solution.  This  ability  is  not  given  to  all, 
and  many  men,  no  matter  how  gifted  they  may  be  in  other  respects,  are 
not  dextrous  with  their  hands,  and  cannot  efficiently  apply  mechanical 
apparatus.  Even  minutely  detailed  descriptions  do  not  certainly  remove 
this  difficulty,  for  the  indications  and  methods  vary  with  the  cases. 
Thus,  some  of  the  supporters  of  Bardenheuer's  method  of  meeting  each 
indication  by  its  special  traction  device  lament  that  as  commonly  prac- 
tised it  fails  to  give  good  results. 

Zuppinger  has  devised  splints  for  making  traction  by  the  weight  of 
the  limb  in  fracture  of  the  leg  and  of  the  thigh,  with  the  knee  and  hip 
flexed,  which  have  been  favorably  noticed  in  Germany  and  bwitzerland. 
While  the  device  seems  to  be  efficient  in  fracture  of  the  leg,  in  that  of 
the  thigh  it  seems  to  me  to  be  essentially  identical  in  action  with  the 
double  inclined  plane,  and  both  seem  to  require  more  constant  attention 
and  ready  apprehension  of  mechanical  conditions  than  can  be  expected 
in  general.      I   think  suspension  of  tlie  leg  with    the    knee    similarly 
flexed  would  more  easily  and   surely  give  the  desired  mechanical   con- 
ditions in  fracture  of  the  thigh.     The  splints  are  described  in  detail   in 
an  article  by  Montandon  in  the  Archives  de  Ghirurgic,  1908,  p.  10-j. 

Direct  Fixation  of  the  Fragments, 

This  can  be  effected  in  a  variety  of  ways,  the  types  being  the  suture, 
ligature,  pin,  and  central  or  external  brace.  Even  the  plan  of  baring 
the  ends  and  engaging  tlieni  in  a  ferrule  of  bone  has  been  employed 
in  a  few  cases. 

In  determining  the  advisability  of  resort  to  it  in  any  case  or  in  mak- 
ing choice  of  a  method,  consideration  should  be  given  to  the  following 


112  FRACTURES. 

facts:  The  cases  of  fracture  of  the  shaft  of  a  long  bone  in  which  suf- 
ficient reduction  cannot  be  maintained  by  a  suitable  external  dressing 
are  very  rare.  The  cases  are  more  frequent  in  whicli  it  cannot  be  com- 
pletely made,  or  in  which  it  cannot  be  certainly  maintained  during  the 
application  of  the  dressing.  To  make  complete  reduction  exposure  of 
the  seat  of  fracture  may  be  necessary,  and  in  some  fractures  thus 
exposed  and  in  some  compound  ones  temporary  direct  fixation  of  the 
fragments  may  be  adyisable.  In  fractures  of  articular  extremities  the 
ditiiculty  is  in  making  reduction  (or  in  being  certain  that  it  has  been 
made)  rather  than  in  maintaining  it,  the  exceptions  being  cases  of 
extensiye  splintering.  In  fracture  of  apophyses  to  which  powerful 
muscles  are  attached,  such  as  the  olecranon,  the  coracoid  process,  the 
greater  tuberosity  of  the  humerus,  the  tuberosity  of  the  os  calcis,  it 
may  be  impracticable  to  maintain  a  position  of  the  limb  in  which  the 
muscle  is  so  fully  relaxed  that  it  will  not  renew  the  displacement  eyen 
if  it  can  be  corrected,  and  in  such  the  proper  relations  of  the  fragments 
can  be  secured  only  by  direct  fixation ;  but  in  most  of  such  cases  the 
continuity  is  maintained  by  periosteal  or  fascial  attachments  which 
ensure  a  union,  bony  or  fibrous,  sufficient  for  satisfactory  function. 

Another  fact,  to  which  I  think  far  too  little  attention  has  been  giyen, 
but  of  which  I  haye  been  conyinced  by  many  obseryations,  is  that  the 
presence  of  a  foreign  body,  eyen  if  sterile  and  unconnected  with  sup- 
puration, in  bone  at  or  near  the  line  of  fracture  notably  exaggerates 
and  prolongs  the  preliminary  rarefaction  of  the  bone.  I  belieye  this 
influence  may  e\en  cause  failure  of  union  by  transformation  of  a  con- 

FiG.  64. 


Fracture  of  femur  remaining  ununited  a  year  after  wiring.     Note  detachment  of  the  wire. 

siderable  portion  of  the  bone  into  fibrous  tissue,  for  in  seyeral  cases  in 
which  I  haye  operated  for  failure  of  union  seyeral  weeks  or  months 
after  a  wire  suture  has  been  applied  to  the  fracture  I  haye  found  the 
suture  lying  free,  and  the  ends  of  the  fragments  thinned  and  pointed 
and  separated  by  a  considerable  intermediate  mass  of  fibrous  tissue. 
That  the  holes  pierced  for  such  sutures  enlarge,  and  that  the  bone  in- 


TREATMENT.  113 

eluded  in  the  loop  wholly  disappears  is  a  common  observation,  and  I 
believe  the  same  change  is  promoted  for  a  considerable  distance  round 
about,  and  although  this  ill  effect  is  not  to  be  expected  always  to 
follow,  yet  its  possibility  should  be  seriously  considered.^ 

iNIr.  W.  A.  Lane-  claims,  with  skiagrams  to  support,  that  this  ab- 
sorption does  not  take  place  if  the  fixation  is  solid  and  the  operation 
done  with  the  minute  attention  to  aseptic  detail  which  he  gives  it. 
That  may  be  so.  I  do  not  know;  but  the  evidence  is  overwhelming 
that,  as  currently  applied,  a  wire  or  nail  passing  across  the  line  of  frac- 
ture does  have  this  effect.  It  is  possible  that  the  screws  of  his  plates, 
being  placed  relatively  far  from  the  area  of  fracture,  do  not  exert  so 
much  of  this  harmful  influence,  but  the  reports  of  cases  in  current  lit- 
erature show  that  in  others'  hands  they  become  loose.  Plate  IV  shows 
the  condition  in  a  case  which  came  to  my  knowledge  just  after  the 
above  was  written.  The  skiagram  was  taken  five  months  after  the 
application  of  the  plate.  The  amount  of  absorption  of  bone  is  shown 
by  the  rounding  of  the  ends  and  the  gap  between  them.  At  the  sub- 
sequent operation  for  the  relief  of  the  pseudarthrosis  and  the  removal 
of  the  plate  the  latter  was  found  entirely  loose.  Roberts  (Annals  of 
Surg.,  1913,  vol.  Ivii.,  p.  545)  shows  that  the  use  of  Lane's  plates  delays 
union  and  may  occasionally  cause  its  failure. 

In  my  judgment  direct  fixation  by  suture  or  pins  should  therefore 
be  only  temporary,  with  the  view  merely  of  holding  the  fragments 
together  during  the  application  of  a  dressing  and  for  a  few  days  there- 
after, and  that  the  loop  of  a  suture  should  include  only  a  small  portion 
of  the  cortical  layer.  Possibl}^  silk  and  silkworm  gut  are  less  injurious 
than  vnre,  although  I  have  known  both  wholly  to  free  themselves  in 
the  same  manner  as  wire,  and  I  am  not  willing  to  advise  against  their 
use  as  absolutely  as  I  do  against  that  of  wire,  but  I  believe  that  with 
.  care  in  handling  strong  catgut  will  give  all  we  ought  to  seek  to  obtain 
from  a  suture.  An  ingenious  device  for  temporary  fixation  is  offered 
by  Dr.  G.  W.  Hawley^  in  the  form  of  a  double  wire  loop  thrown  about 
the  bone  and  held  tight  by  engagement  about  the  end  of  a  thin  bar 
the  shaft  of  which  extends  through  the  dressings.  It  can  be  easily 
freed  and  removed. 

Temporary  fastening  by  nails  or  pins  is  applicable  mainly  to  spongy 
portions  of  bone;  it  has  been  suggested  for  fractures  of  the  shaft  in  the 
form  of  a  long  pin  passed  through  the  pieces,  which  are  further  secured 
by  a  thread  thrown  several  times  over  the  point  and  the  shaft;  by  with- 
drawing the  pin  the  thread  is  freed.     In  Parkhill's  clamp  one  or  two 

1  Mumford  (Boston  Medical  and  Surgical  Journal,  May  10,  1894),  in  a  report  on  300 
cases  of  compound  fracture,  noted  that  in  27  primary  wiring  of  the  fragment  was  done, 
and  that  in  7  of  these  necrosis  followed. 

V.  Brunn  (Beilage  zum  Ztlblatt.  fiir  Chir.,  1906,  p.  123)  examined  12  cases  of  fracture 
of  the  patella  treated  by  writing.  There  was  bony  union  in  only  3;  one  silver  loop  was 
still  in  place,  one  had  been  freed  by  absorption  of  the  enclosed  bone,  all  the  others  had 
broken  into  two  or  more  pieces,  and  in  3  cases  pieces  of  the  wire  were  found  free  in  the 
cavity  of  the  joint,  causing  constant  discomfort. 

2  Lane:  Surgery,  Gynecology  and  Obst.,  1909,  vol.  viii.,  p.  344. 
^Hawley:  Interstate  Med.  .lour.,  1916.  vol.  xxxiii..  No.  4. 


114 


FRACTURES. 


pins  are  passed  through  the  skin  in  each  fragment  near  the  fracture 
and  held  together  by  a  plate.  An  objection  to  pins  reaching  to  the 
exterior  is  the  difficulty  of  keeping  their  track  aseptic;  the  objection 
is,  of  course,  greater  when  the  pin  passes  to  the  fracture. 

A  ligature  thrown  circularly  or,  better,  obliquely  in  notches,  about 
the  bone  has  been  employed. 

Fixation  by  a  bone  pin  inserted  lengthwise  into  the  medullary  canal 
has  long  been  occasionally  practised,  but  with  only  moderate  success 
at  first.    Of  late  years  the  results  have  been  better. 


Fig.  65. 


Lane's  plates. 

In  fracture  of  the  patella,  in  which  a  special  indication  for  fixation 
exists,  ample  support  can  be  given  by  catgut  sutures  in  the  fibro- 
periosteal  covering  of  the  front  of  the  bone  and  in  the  lateral  expansions 
close  beside  the  bone,  or  even  by  a  long  mediate  suture  crossing  the 
front  of  the  bone  and  embracing  the  tendon  above  and  the  ligamentum 
patellae  below.  The  exposure  and  handling  necessary  for  drilling  the 
bone  are  thus  avoided,  with  consequent  diminution  of  risk.  Somewhat 
similar  methods  can  be  used  in  fracture  of  the  olecranon  when  the 
indication  exists. 

Fixation  of  the  fragments  by  a  brace  fastened  against  the  side  of 
the  bone  with  buried  screws,  "plating,"  as  it  is  generally  termed, 
was  first  used,  so  far  as  I  know,  by  Dr.  Wm.  S.  Halsted  upon  a  fracture 


PLATE  IV 


Lane's  Plate,  Five  Months  after  Application.      Absorption  of  Bone; 
Loosening  of  Screws;    Failure  of  Union. 


TREATMENT. 


115 


of  the  humerus  at  the  Roosevelt  Hospital,  New  York,  in  1885.  The 
suggestion  came  to  him  as  an  improvement  upon  Hansmann's^  plates, 
fixed  by  long  pins  extending  beyond  the  skin,  which  he  had  seen  under 
experimentation  in  Schede's  service.  More  than  twenty  years  later 
it  was  forced  upon  the  attention  of  the  profession  by  the  earnest 
advocacy  of  Sir  Arbuthnot  Lane  supported  by  a  large  personal  experience 
in  its  use.  This,  its  real  introduction,  was  received  with  a  favor  ap- 
proaching enthusiasm  in  some  quarters,  and  it  has  been  so  widely 
practised  and  discussed  in  the  intervening  years  that  some  conclusions 
concerning  its  proper  range  and  limitations  may  properly  be  drawn. 


Fig.  66. 


Fig.  67. 


rtbm/ 
Graft 


Albee's  saw. 


Bone  insert. 


One  fact  is  clearly  established,  namely,  its  successful  use,  including 
in  that  term  not  only  the  application  of  the  plate  but  also  the  avoid- 
ance of  septic  complications  during  repair,  requires  special  instruments, 
exceptional  manual  dexterity  and  experience  not  only  in  general 
surgery  but  also  in  the  operation  itself.  The  latter  is  also  true  of  many 
other  operations,  and  while  it  does  not  forbid  the  attempt  by  the 
inexperienced,  it  imposes  a  serious  responsibility  in  the  decision  and 
extreme  care  in  the  execution.  Thus,  a  friend  with  large  hospital 
experience  tells  me  that  of  his  first  1 1  cases  he  had  to  remove  7  plates, 
of  the  following  14  he  had  to  remove  none.  And  the  Committee  on 
Fractures  of  the  American  Surgical  Association  in  1915  reported  "out 
of  210  operations  for  closed  fractures  (all  of  them  clean  wounds,  none 
of  them  primarily  infected)  no  less  than  twelve  wounds,  or  over  5  per 
cent,  of  the  whole  series,  became  infected  during  the  operation.  .  .  . 
Such  a  record  of  infection  ...  is  scandalous  in  a  series  of  opera- 
tions for  simple  fractures.  And  it  may  be  remarked  that  while  all  the 
good  operative  results  were  obtained  by  good  surgeons,  the  infected 
cases  are  not  the  sole  property  of  bad  surgeons.     In  2  cases  where 

1  Hansmann:  Verhand.  Deutsch.  Gesel.  fiir  Chir.,  1SS6,  i,  p.  134. 


116  FRACTURES. 

infection  was  caused  by  the  operation  it  proved  so  severe  that  amputa- 
tion had  to  be  done,  one  for  fracture  of  the  femur  and  one  for  fracture 
of  the  tibia."  These  statistics  included  only  hospital  cases  in  seven 
large  cities.  That  this  percentage  of  accident  and  disaster  is  below  the 
general  average  is  the  belief  of  many  who  have  written  on  the  subject, 
and  it  is  beyond  question  that  a  serious  toll  not  only  of  limb  but  also 
of  life  has  been  taken. 

It  is  clear,  then,  that  the  operation  is  a  serious  one  with  serious 
risks  and  should  be  done  only  when  special  indications  exist  and  so 
far  as  possible  only  by  men  with  ample  surgical  experience. 

The  disadvantages  do  not  end  with  recovery  from  the  operation. 
Many  reports  of  individual  experience  have  been  made  and  a  few 
writers^  have  summarized  them.  The  plate  is  occasionally  a  source 
of  irritation  and  needs  to  be  removed.  Sinuses  and  even  sequestra 
form  about  the  screws.  There  is  a  fairly  general  agreement  that 
union  requires  more  time  than  in  fractures  not  operated  on;  this, 
I  think,  is  due  not  to  the  presence  of  the  plate  but  to  the  exposure  of 
the  fracture,  for  I  long  ago  noted  it  in  fractures  that  had  been  cut  down 
upon  but  not  plated.  Loss  of  bone  at  the  fracture  by  exaggerated 
rarefaction  has  been  observed,  and  even  a  general  weakening  of  the 
bone  in  the  neighborhood  of  the  screws  and  secondary  fracture.  Stiff- 
ness of  a  neighboring  joint  is  not  infrequent,  especially  of  the  knee 
after  plating  of  the  femur;  this  is  probably  the  result  of  implication 
of  the  muscle  in  the  operation  and  the  scar. 

The  results  in  respect  of  function  also  are  not  without  reproach. 
The  anatomical  restoration  of  the  shape  of  the  bone  is  usually  good, 
but  the  percentage  of  full  restoration  of  function  is  even  less,  according 
to  the  Committee  on  Fractures  of  the  American  Surgical  Association 
(loc.  cit.),  than  that  of  fractures  treated  without  operation.  This,  of 
course,  is  a  not  entirely  fair  comparison,  for  most  of  the  cases  plated 
have  probably  been  of  a  kind  that  would  have  yielded  under  non- 
operative  treatment  less  favorable  results  than  the  average,  but  it 
shows  that  the  method  can  offer  at  the  best  only  a  mitigation  of  a  poor 
result  and  not  its  complete  avoidance.  The  Committee  say  further: 
"if  only  moderate  reduction  is  obtained  the  proportion  of  good 
functional  results  is  very  much  higher  when  no  operation  is  done. 
This  brings  one  to  the  conclusion  that  unless  the  surgeon  is  reasonably 
certain  of  securing  accurate  anatomical  reduction  by  operative  means 
he  will  do  better  to  leave  the  fracture  unreduced.  Certainly  under 
fifteen  years  of  age,  when  only  moderate  reduction  secures  good  function 
in  as  high  as  85  per  cent,  of  cases,  there  is  very  little  excuse  for  operation 
as  an  habitual  practice." 

In  short,  the  method  is  one  that  should  be  rigidly  restricted  to  a 
small  proportion  of  carefully  selected  cases.  And  this  applies  equally, 
though  perhaps  to  a  somewhat  less  extent,  to  fixation  by  bone  plates 
or  inserts  and  intramedullary  bone  dowels.    I  think  the  temptation  to 

1  Edington:  Glasgow  Med.  Jour.,  July,  1914;  Frank:  Surg.,  Gynecol,  and  Obst., 
Dec,  1915,  p.  783. 


TREATMENT.  117 

resort  to  it  is  less  when  the  surgeon  fully  grasps  the  capabilities  of 
exterior  splints  and  their  adequate  application. 

For  the  performance  of  this  operation  certain  special  instruments 
are  necessary:  a  double  adjustable  clamp  by  which  the  two 
main  fragments  can  be  firmly  held  together  while  the  screws  are 
inserted;  plates  of  various  shapes  (Fig.  65)  with  countersunk  screw 
holes;  special  screws  and  preferably  special  instruments  for  inserting 
and  fastening  the  screws.  It  is  also  well  to  have  forceps  and  artery 
clamps  with  long  handles  so  that  the  operation  may  be  done  without 
touching  the  tissues  with  the,  even  gloved,  hand. 

Bone  plates  fastened  with  bone  pegs  have  occasionally  been  used 
instead  of  metal  ones;  it  is  claimed  that  their  rather  prompt  erosion 
by  the  tissues  obviates  the  irritation  caused  by  metal. 

The  bone  inlay,  for  which  we  are  mainly  indebted  to  Dr.  Albee 
and  which  at  first  was  chiefly  used  in  cases  of  non-union  but  is  now 
strongly  recommended  by  many  in  preference  to  metal  plates,  consists 
in  placing  a  bar  of  bone  about  J  inch  square  and  3  to  5  inches  long  in  a 
gap  cut  through  the  cortex  of  the  ends  of  the  two  fragments.  The 
groove  is  cut  with  an  electric  saw  having  two  parallel  blades,  I  inch 
or  so  apart  and  the  attached  end  of  the  immediate  piece  is  chiseled 
through.  Some  strip  back  the  periosteum  first,  and  replace  it  over  the 
inlay.  The  inlay  has  usually  been  taken  from  the  tibia  of  the  patient, 
with  or  without  its  periosteum ;  it  can  be  obtained  by  sawing  across  the 
crest  at  the  two  ends  of  the  proposed  piece,  cutting  it  off  with  a  chisel, 
and  then  trimming  it  to  fit,  or  by  cutting  through  the  side  of  the  tibia 
with  the  electric  circular  saw,  and  cutting  the  piece  free  at  each  end 
with  a  chisel.  It  may  be  fixed  in  place  by  the  restored  periosteum,  a 
couple  of  catgut  ligatures  thrown  about  the  bone,  or  by  catgut  sutures 
passed  through  holes  drilled  through  the  cortex  close  beside  it.  Some 
surgeons  claim  equally  good  results  with  inlays  taken  from  animals, 
and  if  the  claim  is  well  founded  the  practice  is  preferable  not  only 
because  it  spares  a  second  wound  but  also  because  it  has  been  found 
that  the  tibia  is  sometimes  seriously  weakened  by  the  removal. 

Buchanan  uses  for  the  inlay  the  pieces  removed  in  cutting  the  groove: 
he  makes  one  long  and  the  other  short,  places  the  long  one  across  the 
line  of  fracture  and  the  short  one  in  the  gap  left  by  the  shifting  of  the 
long  one. 

INIagnuson^  recommends  an  ivory  plate  inserted  edgewise  through  a 
longitudinal  slot  cut  with  the  twin  circular  saw  of  a  width  equal  to  the 
thickness  of  the  plate.  The  latter  is  forced  in  across  the  medullary 
cavity  and  fastened  with  two  bone  screws.  Any  excess  remaining 
above  the  surface  of  the  cortex,  of  either  plate  or  screws,  is  cut  away. 

Those  who  may  think  of  resorting  to  it  in  fracture  of  the  thigh 
would  do  well  to  weigh  carefully  the  statistics  given  by  Dr.  Ashhurst^ 
in  a  discussion  of  the  subject  at  the  Philadeljjhia  Surgical  Society: 

•  Jour.  Am.  Med.  Ass.,  vol.  Ixi.,  p.  l.")14. 

2  Ashhurst:  Annals  of  Surgery,  April,  liJll,  p.  588. 


118  FRACTURES. 

40  fractures  of  the  shaft  of  the  femur  with  a  perfect  result  in  60  per  cent., 
and  in  32  per  cent,  "no  disabihty  other  than  a  shght  Hmp."  And  it 
would ^  be  well  also  to  note  the  not  infrequent  reports  of  ensuing 
fatalities/  the  warnings,  and  the  unfavorable  opinions  expressed  in  so 
many  society  discussions.     (See  also  page  85.) 

Removal  of  Permanent  Dressing. 

After  union  has  become  so  firm  that  abnormal  mobility  can  no  longer 
be  recognized  and  pain  is  no  longer  caused  by  handling,  the  permanent 
dressing  may  be  laid  aside.  Other  things  being  equal,  this  removal 
will  be  longest  delayed  after  fracture  of  the  shaft  or  neck  of  the  femur. 
Whether  the  removal  shall  be  permanent  or  intermittent  must  be  de- 
termined by  the  degree  of  exposure  of  the  limb  to  chance  violence, 
M'hich  might  cause  bending  or  refracture.  Thus,  after  fracture  of  the 
thigh  the  patient  may  be  kept  in  bed  or  even  seated  in  a  chair  without 
a  dressing  for  a  week  or  two  before  he  essays  to  walk  with  crutches, 
employing  the  time  to  regain  mobility  at  the  knee  and  ankle.  It  is 
sometimes  prudent  to  reapply  the  dressing  during  the  night  as  a  pre- 
caution against  unguarded  movements.  And  after  fracture  of  the 
humerus  the  dressing  may  be  left  off  during  the  day  and  worn  at  night 
for  the  same  reason.  After  fracture  of  the  patella  it  is  worn  during 
the  day  while  the  patient  is  going  about,  as  a  precaution  against  a  fall, 
and  left  off  at  night.  In  fractures  of  the  lower  limb,  especially  those 
of  the  femur  and  those  that  are  oblique,  the  patient  should  be  enjoined 
to  use  crutches  and  to  bear  little  or  no  weight  upon  the  limb  for  several 
weeks  after  union  has  apparently  become  firm,  lest  an  angular  change 
or  shortening  should  be  slowly  effected.  In  a  Colles  fracture  it  may 
be  left  off  after  two  or  three  weeks  in  order  to  favor  return  of  mobility 
in  the  wrist;  and  in  most  fractures  near  or  involving  joints  a  relatively 
early  permanent  or  intermittent  removal  favors  the  return  of  function. 

Massage. 

Massage  has  shown  itself  after  fracture,  as  after  other  injuries,  so 
efficient  to  overcome  the  earlier  and  later  swellings,  stiffness  of  contigu- 
ous joints,  and  dryness  and  coldness  of  the  surface,  the  conditions  M-hich 
delay  convalescence  and  apparently  prolong  the  period  of  repair,  that 
a  somewhat  exaggerated  impression  of  its  value  has  found  expression 
in  some  quarters,  and  it  has  even  been  proposed  as  a  sole  method  of 
treatment  to  the  exclusion  of  all  retentive  dressings.  To  these  exces- 
sive claims  has  succeeded  a  calmer  and  more  judicial  appreciation  of 
its  merits  and  limitations,  largely  through  the  experience  and  writings 
of  Lucas-Championniere.2  It  appears  to  be  beyond  question  that  by  its 
systematic  and  skilful  use  in  suitable  cases  the  primary  swelling  is 
lessened  and  disappears  more  promptly,  the  circulation  and  skin  more 

1  At  a  meeting  of  the  New  York  Surgical  Society,  Feb.,  1912,  mention  was  made  of 
5  cases  in  which  amputation,  with  1  death,  had  followed  the  use  of  the  method  in  fracture 
of  the  thigh. 

^  Lucas-Championnifere:  Du  massage  dans  le  traitement  des  fractures,  Paris,  1895. 


TREATMENT.  119 

rapidly  regain  their  normal  condition,  the  atrophy  of  the  muscles  is 
less  and  more  promptly  disa])pears,  and  the  joints  more  quickly  lose 
their  sensitiveness  and  regain  the  range  of  motion  which  is  possible 
under  the  changed  skeletal  conditions  ;  possibly  that  range  after  frac- 
ture at  or  near  a  joint  may  be  increased  by  massage  over  what  it  would 
be  without  it,  but  if  so  the  fact  can  hardly  be  demonstrable. 

The  claim  that  repair  of  the  fracture  takes  place  more  promptly  has 
not,  I  think,  been  substantiated  and  seems  to  me,  moreover,  possibly 
inconsistent  with  certain  observations  which  indicate  that  repair  may 
be  delayed  by  insufficiency  of  reaction. 

Whether  these  gains,  which  amount  to  a  little  more  than  a  shortening 
of  the  period  of  after-affects,  are  worth  the  trouble  and  expense  of 
obtaining  them  is  an  economic  rather  than  a  surgical  question,  and  it 
is  clear  that  they  should  be  sought  for  only  when  there  is  no  danger  of 
making  greater  losses  thereby — that  is,  in  cases  in  which  the  tendency 
to  displacement  is  slight  and  can  be  satisfactorily  guarded  against. 
This  is  the  case  with  many  fractures  at  the  ankle,  wrist  and  elbow,  and 
of  the  fibula  alone  ;  and  in  some  of  the  leg,  forearm,  and  arm  protected 
by  moulded  splints  one  splint  will  give  sufficient  protection  while  mas- 
sage is  made  after  removal  of  the  other. 

Massage  is  made  by  light  rubbing  toward  the  trunk  with  the  fingers 
and  then  the  whole  hand,  first  beside  the  fracture  and  then,  as  tolerance 
is  established,  over  it.  The  sittings  should  last  for  tw^enty  or  thirty 
minutes  and  be  repeated  daily.  It  has  seemed  to  me  that  the  repeated 
application  of  the  elastic  bandage  was  equally  advantageous. 

Ambulatory  Treatment.^ 

The  suggestion  made  a  few  years  ago  by  an  instrument  maker  in 
Germany  that  in  fractures  of  the  lower  extremity  splints  should  be 
used  which  would  enable  the  patient  to  walk  during  treatment  has  led 
to  considerable  experimentation,  the  ultimate  result  of  which  seems 
likely  to  be  of  some  benefit  to  the  patient,  although  far  less  than  is 
claimed  by  some  who  have  sought  to  generalize  the  method.  In  esti- 
mating the  value  of  the  suggestion  and  determining  the  extent  to  which 
the  previous  use  of  the  method  can  be  broadened,  we  must  discriminate 
sharply  between  the  different  forms  of  fracture.  A  man  with  a  frac- 
ture of  the  fibula,  of  the  external  malleolus,  even  wdth  a  Pott's  fracture, 
can  often  walk  with  comparative  ease  and  security  under  the  ])rotection 
of  a  plaster-of-Paris  dressing  which  limits  the  motion  of  the  ankle- 
joint  and  prevents  lateral  strain  upon  it.  And  so  too  with  fracture  of 
the  patella.  To  that  extent  there  is  nothing  new  in  the  idea,  so  far  at 
least  as  the  freedom  from  confinement  is  concerned.  The  claim  now 
is  that  the  method  can  be  extended  to  fracture  of  both  bones  of  the 
leg  and  even  of  the  femur,  that  the  loss  of  time  and  earning  capacity 
is  thereby  lessened,  that  union  takes  place  more  rapidly,  and  that  the 
joints  more  promptly  regain  their  freedom  of  motion  and  the  whole 

'  For  a  thorough  presentation  of  the  history  and  claims  of  the  method,  see  Guitard:  De 
la  methode  ambulatoire  dans  les  traumatismes  osseux  de  membre  inferieur,  Paris,  1903. 


120  FRACTURES. 

limb  its  normal  condition.  The  comparison  in  respect  to  the  last  three 
points  is  one  that  is  notoriously  difficult  to  make  with  accuracy,  and  it 
has  not  been  helped  by  the  statistics  that  have  been  published,  for  they 
have  included  a  large  proportion  of  the  slighter  cases,  and  I  think  it 
must  still  be  held  that  the  claim  has  not  been  substantiated.  As  for 
the  pecuniary  value  of  ambulation  on  the  splint,  the  advantage  seems 
to  me  to  be  illusory  ;  the  splint  is  in  that  respect  no  better  than  a 
crutch,  and  although  it  may  perhaps  be  at  times  more  convenient  it  is 
at  others  less  so. 

On  the  other  hand,  the  method  exposes  to  risks  of  displacement  and 
of  healing  with  deformity  which,  in  my  judgment,  outweigh  even  the 
claimed  advantages,  and  the  statistics  show  that  the  risk  is  a  real  one 
and  that  damage  results  in  a  considerable  proportion  of  cases. 

The  principle  of  construction  of  an  ambulatory  splint  for  a  fracture 
of  the  leg  is  to  make  it  of  plaster  of  Paris  in  a  way  to  combine  reten- 
tion in  the  ordinary  manner  with  a  support  on  each  side  which  extends 
well  below  the  sole  and  takes  the  weight  of  the  body  through  its  attach- 
ment to  the  splint  well  above  the  fracture,  the  lower  segment  of  the 
limb  hanging  between  these  supports  and  receiving  none  of  the  weight. 
For  a  fracture  of  the  thigh  the  dressing  is  a  combination  of  a  fixed 
dressing  and  a  hip-splint  which  receives  the  weight  of  the  body  at  the 
pelvis. 

It  is  admitted,  I  think,  by  all  supporters  of  the  method  that  it 
should  not  be  employed  until  after  the  primary  swelling  has  subsided 
and  the  early  hardening  of  the  soft  parts  about  the  fracture  has 
appeared,  say  after  a  fortnight  in  a  fracture  of  both  bones  of  the  leg. 
The  limb  is  then  covered  with  a  plaster  dressing  applied  directly  over 
the  skin  except  along  the  sole,  where  it  is  separated  from  it  by  a  layer 
of  cotton  about  two  inches  thick.  Along  the  sole  and  on  the  sides  of 
the  limb  the  dressing  is  made  very  thick  and  strong  and  is  sometimes 
reinforced  by  lateral  strips  of  wood  or  metal.  The  other  foot  must  be 
correspondingly  raised  by  a  thick  sole.  It  is  beyond  question  that  if 
the  method  is  employed  the  patient  should  be  kept  under  observation 
and  the  same  precautions  as  regards  removal  for  inspection  should  be 
taken  as  have  been  shown  to  be  necessary  with  other  splints. 

A  safer  plan,  if  it  is  essential  that  the  patient  should  walk,  is  to  use 
an  ordinary  hip-splint  for  ambulation,  the  broken  leg  being  separately 
encased  in  plaster.  The  same  plan  can  be  employed  in  the  later  stages 
of  fracture  of  the  femur. 

I  have  found  that  patients  can  sometimes  walk  about  with  the  aid 
of  two  lateral  strips  of  wood  placed  outside  of  an  ordinary  plaster 
dressing  after  it  has  hardened  and  supported  by  a  shoulder  or  collar  of 
plaster  at  its  upper  part,  or  by  a  light  apparatus  of  two  iron  side-pieces 
fastened  over  a  plaster  dressing  with  straps  and  buckles. 

At  the  Congress  of  the  International  Society,  held  at  Brussels, 
September,  1911,  Prof.  Dollinger  showed  the  ambulatory  dressings 
w^ith  which  he  had  healed  81  fractures  of  the  thigh  and  144  fractures  of 
the  leg.  In  fractures  of  the  thigh  the  fixed  points  are  taken  at  the  tuber 
ischii  and  the  condyles  of  the  femur.  For  the  details  I  must  refer  to  the 
original  reports.     (See  also  Treatment  of  Fractures  of  Shaft  of  Femur.) 


TREATMENT. 


121 


Management  of  the  Joints. 

The  joints  iu  the  formation  of  which  the   broken  bone  takes  part, 
and   often   more  distant  ones,  become   stiif  and   sensitive  during  the 


Fig.  68. 

^^^^H^^^  .&> 

~4 

1 

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^i^ 

MflH^BJBltflft^'-'' 

ImIs 

1 

^H 

fB^ 

S"' 

H 

M^^""™** 

^m^^^^^Hfegl^rjH 

H^^ 

^^ 

^ 

k. 

Bony  anchylosis  after  supracondyloid  fracture. 

period  of  repair  and  remain  so  for  a  longer  or  shorter  time  thereafter. 
This  disability  is  specially  marked  and  may  become  permanent  in  the 
old  and  rheumatic  when  the  fracture  has  involved  the  joint  or  when  the 
joint  has  been  coincidently  sprained,  and  in  the  joints  of  the  hand  even 
when  the  fracture  is  of  the  arm  or  forearm.  The  causes  are  varied  and 
numerous,  usually  unavoidable,  and  sometimes  irremovable.  The  more 
important  and  permanent  are  those  arising  from  change  in  the  shape  of 
the  articular  end  of  the  bone  by  uncorrected  displacement  of  a  fragment 
or  by  excessive  formation  of  callus,  or  by  anchylosis,  and,  in  less  de- 
gree, from  thickening  and  retraction  of  the  periarticular  tissues  and  the 
formation  of  adhesions  within  the  joint  following  its  sprain  or  its  share 
in  the  fracture.  These  are  all  the  result  of  the  primary  injury  and 
of  the  inflammatory  reaction,  overgrowth  of  callus  being  most  com- 
mon in  the  young  because  of  the  activity  of  the  periosteum  in  bone 
formation  at  that  period.  Anything  ^vhich  diminisiies  that  reaction 
and  shortens  its  duration  will,  therefore,  tend  to  diminish  these  ham- 
pering consequences;  anything  which  augments  it  Avill  add  to  them. 
This  gives  us  a  standard  by  which  to  measure  the  value  and  appropri- 
ateness of  any  method  of  treatment.  Rest,  massage,  elastic  compres- 
sion have  long  since  proved  their  value  to  reduce  inflammation  in 
joints  and  to  remove  exudates  from  within  them  and  from  the  peri- 
articular tissues;  and  moderate  use,  active  or  ])assive,  to  increase  the 
range  of  motion  after  the  inflammatory  reaction  has  ceased.  Tlie 
importance,  and  especially  the  respective  timeliness,  of  these  two 
9 


122  FRACTURES. 

opposing  methods  need  to  be  fully  grasped.  The  surgeon's  dread  of 
anchylosis,  his  anchylophobia,  as  it  has  been  termed,  too  often  leads 
him  to  move  and  even  to  force  a  joint  while  such  motion  will  still  be 
painful  and  will  be  followed  by  an  increa.se  in  the  reaction  and  a  reduc- 
tion of  the  range  of  motion,  and,  on  the  other  hand,  if  he  has  well 
grasped  the  corresponding  principle  he  is  in  danger  of  undidy  prolong- 
ing confinement  and  thereby  postponing  and  perhaps  restricting  the 
restoration  of  function.  The  criterion  is  a  plain  one  :  so  long  as  the 
joint  is  swollen  and  hot,  so  long  as  its  use  is  followed  by  an  increase  of 
swelling  and  heat  and  by  persistent  pain,  so  long  must  it  be  kept  at 
rest  and  so  long  must  active  treatment  be  limited  to  massage  or  elastic 
compression  ;  and,  as  a  rule,  this  attitude  of  non-interference  may  be 
maintained  v/ithout  harm  until  after  union  of  the  fracture  has  become 
complete.  Then  he  may  resort  to  passive  motion  or  may  encourage  the 
patient  to  gradually  increasing  use  of  the  limb,  and  he  will  see  the  stiff 
joint  rapidly  regain  its  functions. 

Forcible  passive  motion,  with  or  without  anaesthesia,  is  always  harm- 
ful before  the  second  month,  and  even  after  that  time  it  is  far  more 
likely  to  do  harm  than  good.  About  the  only  condition  in  which  it 
can  really  help  is  that  of  isolated  cord-like  adhesions  within  the  joint 
which  can  thus  be  broken  wdthout  the  probability  of  their  reunion. 
Such  a  condition  we  have  every  reason  to  believe  to  be  very  rare. 
When  the  method  is  employed  to  increase  a  range  of  motion  that  has 
been  restricted  by  the  common  causes,  such  as  broad  adhesions,  retrac- 
tion of  the  capsule  with  periarticular  thickening,  and  bony  irregulari- 
ties, it  accomplishes  its  object  only  by  creating  lacerations  which 
necessitate  immediate  immobilization  in  order  to  check  inflammatory 
reaction  and  which  in  healing  re-create  the  original  or  similar  conditions 
and  even  increase  them.  The  procedure  should,  I  think,  be  almost 
wholly  abandoned,  and  in  its  place  we  should  resort  to  massage,  con- 
stant use  within  existing  limits,  and  possibly  to  the  recently  intro- 
duced method  of  prolonged  exposure  to  high  dry  temperatures,  and 
these  failing,  I  should  prefer  to  expose  the  joint  by  incision  in  order  to 
remove  such  intra-articular  obstacles  as  might  exist  and  be  removably 
rather  than  blindly  to  seek  to  break  and  tear  them  without  knowing 
what  and  where  they  are.  Yet  it  must  be  added  that  occasionally 
joints  at  a  distance  from  the  injury  may  become  so  stiff  and  sensitive 
that  the  patient  can  make  no  progress  in  freeing  them  by  use  of  the 
limb,  but  if  once  moved  freely  under  anaesthesia  they  retain  the  mo- 
bility and  lose  the  sensitiveness.  At  the  ankle  particularly  such  for- 
cible correction  of  the  position  of  the  foot  will  enable  the  patient  to 
stand  upon  it  and  thus  begin  the  gentle  use  which  is  needed. 

This  general  rule  of  immobilization  needs  one  important  addition 
with  respect  to  the  fingers.  In  the  treatment  of  all  fractures  of  the 
arm  and  forearm  the  fingers  and  thumb  should  be  left  free  and  the 
patient  should  be  enjoined  constantly  to  move  them  ;  in  addition,  if 
the  dressing  must  include  a  portion  of  the  hand  it  should  be  so  arranged 
that  the  wrist  will  be  in  slight  dorsal  flexion,  the  fingers  flexed  but  free 
to  be  extended,  and  the  thumb  abducted,  because  these  attitudes  tend 
to  retard  and  diminish  the  ill  effects  of  confinement  and  lack  of  use. 
If  the  fine-ers  must  be  confined  it  should  be  in  flexion. 

O 


TREATMENT.  123 

COMPOUND    FRACTURES. 

The  points  here  to  be  considered  are  those  connected  with  the  man- 
agement of  the  wound  of  the  soft  parts  and  the  modifications  imjjosed 
by  its  presence  and  character  uj^on  the  details  of  reduction  and  reten- 
tion of  the  fracture. 

A  very  important  difference  is  that  between  fractures  by  direct  and 
fractures  by  indirect  violence,  because  in  the  former  the  wound  is 
usually  large  and  so  contused  that  its  prompt  uncomplicated  healing 
cannot  be  expected,  while  in  the  latter  it  is  usually  made  from  within 
outward  by  the  sharp  end  of  a  fragment,  is  small  and  clean,  and  may 
confidently  be  expected  to  heal  within  a  few  days  under  proper  care, 
thus  transforming  the  fracture  into  a  simple  one  and  putting  an  end  to 
the  special  dangers  which  make  the  injury  so  redoubtable.  Moreover, 
in  the  former,  especially  when  the  muscles  as  well  as  the  skin  are  lacer- 
ated, the  more  virulent  streptococcus  and  even  the  B.  aerogenes  infec- 
tions develop  with  exceptional  frequency.  I  have  long  noted  this 
fact,  the  frequent  development  of  these  redoubtable  infections  amid 
bruised,  torn  muscles,  when  slighter  contemporaneous  wounds  received 
under  similar  personal  conditions  and  apparently  exposed  to  the  same 
contaminations  ran  an  uneventful  course.  It  is  unreasonable  to  assume 
that  contamination  is  limited  to  the  severe  cases ;  it  must  occur  also  in 
some,  perhaps  in  many,  of  the  others.  The  reason  of  its  development 
in  one  and  not  in  another  must  then  be  sought  in  the  differing  condi- 
tions, and  I  think  it  may  be  found  in  the  lowered  vitality  of  the  bruised 
muscles,  in  the  products  of  their  changed  metabolism,  or  in  their  low- 
ered power  of  resistance. 

These  two  varieties  differ  so  greatly  in  prognosis  and  treatment  that 
I  shall  seek  to  emphasize  the  distinction  betAveen  them  by  a  separate 
description,  although  it  must  be  admitted  that  the  special  cliiiiculties  and 
dangers  which  characterize  those  by  direct  violence  may  also  exist  in 
those  by  indirect  violence  in  consequence  of  unusual  associated  condi- 
tions more  or  less  independent  of  the  mode  of  production.  The  essen- 
tial difference  is  in  the  condition  of  the  wounded  tissue  :  in  the  one,  a 
lacerated  contused  wound,  some  of  the  skin  about  which,  even  if  appar- 
ently uninjured,  is  almost  certain  to  slough  ;  in  the  other,  a  small 
clean  wound  almost  as  fit  to  heal  as  if  it  had  been  made  on  the  operat- 
ing table. 

Compound  Fracture  by  Indirect  Violence,  or  with  a  Small, 
Clean  Wound. 

The  patient  is  anaesthetized  and  the  skin  about  the  wound  is  cleaned 
as  for  an  operation.  If  the  point  of  a  fragment  projects  through  the 
skin  and  is  rather  tightly  grasped  by  it  the  wound  must  be  freely 
enlarged,  and  it  and  the  bone  irrigated  with  an  antiseptic  solution, 
such  as  the  1-1000  bichloride,  or  tincture  of  iodine,  one  drachm  in  a 
pint  of  normal  salt  solution,  or  the  solution  of  hypochlorite  of  soda 
(see  below,  p.  126) ;  reduction  is  then  made,  the  limb  pressed  to  force 
out  the  escaped  blood,  the  wound  closed  with  interrupted  sutures  at 


124 


FRACTURES. 


half-inch  intervals,  and  a  sterile  or  antiseptic  dressing  applied,  with 
temporary  splints.  Exceptionally  it  may  be  advisable  to  insert  a 
drain  of  gauze  or  rubber,  or  to  explore  the  wound  to  aid  the  reduction 
or  to  remove  fragments,  or  to  secure  a  torn  vessel,  but  the  less  the 
wound  is  handled  the  better,  because  of  the  risk  of  contamination 
by  the  jBngers. 

About  a  week  later  the  dressing  is  removed  and  if  all  has  gone 
well  the  fracture  is  thenceforth  treated  as  a  simple  one;  but  if  infec- 
tion has  occurred  the  measures  described  in  the  next  section  must  be 
employed. 

Compound  Fracture  by  Direct  Violence,  or  with  a  Contused  or 

Infected  Wound. 

The  patient  is  ansesthetized,  the  skin  cleaned^  and  the  wound  thor- 
oughly washed  out  with  an  antiseptic  solution;  loose  fragments  are 
removed,  the  ends  of  the  bones  regularized  if  necessary,  and  the  deeper 
layers  of  muscle  and  fascia  fastened  together  by  sutures  so  as  to  give 
support  to  the  fragments;  if  deemed  necessary  a  catgut  or  temporary 

Fig.  69. 


Combined  plaster  encasement  and  splints  in  ronipound  fracture. 

suture  may  be  placed  in  the  bone  to  hold  the  fragments  together. 
Then  the  enveloping  fascia  is  sutured  at  a  few  points,  not  too  closely, 
and  the  skin  sutured  so  far  as  its  condition  permits.  Drains  of  rubber 
or  gauze  are  inserted,  and  a  dressing  placed  over  all.  The  limb  is 
then  placed  in  splints  that  will  permit  a  change  of  dressing  with  the 
least  disturbance  of  the  fragments;  for  the  leg  Volkmann's  splint  is 
convenient,  or  the  plaster  stocking  (p.  102),  or  moulded  anterior  and 
posterior  splints,  one  of  which  is  placed  if  possible  next  the  skin  and 
protected  by  rubber  tissue  or  Croux's  paste  (p.  103)  from  soaking  by 
the  discharge  (Fig.  70).  Later  in  the  course,  if  the  case  does  well,  an 
interrupted  or  fenestrated  splint  may  be  used,  but  the  dressing  occu- 
pying the  fenestra  or  interval  must  be  bound  on  very  snugly  or  the 
tissues  under  it  will  become  oedematous  and  project  through  the  open- 


TREATMENT. 


125 


ing.    Suspension  and  elevation  add  to  the  comfort  and  welfare  of  the 
patient  and  often  to  the  convenience  of  the  surgeon. 

For  the  thigh  Hodgen's  splint  is  usually  the  most  convenient,  but 
the  double  inclined  plane  is  sometimes  better.  Dr.  Hitzrot  has  used 
plaster  splints  and  a  temporary  Lane  plate,  leaving  the  wound  open 
and  removing  the  plate  after  three  or  four  weeks.  This  seems  well 
adapted  to  maintain  coaptation  when  external  support  is  insufficient. 
For  the  arm,  especially  in  fractures  near  the  elbow,  I  like  vertical 
suspension;  it  seems  to  keep  down  the  reaction  very  efficiently,  but 
moulded  splints  are  very  convenient,  as  they  also  are  for  the  forearm. 

Fig.  70. 


Compound  fracture.     Dressing  and  plaster  splint. 

The  condition  of  the  skin  about  the  wound  in  these  fractures  demands 
close  inspection,  for  it  is  usually  much  more  seriously  and  extensively 
affected  than  its  appearance  indicates.  It  is  almost  invariably  stripped 
up  from  the  underlying  parts  for  a  considerable  distance  and  certain 
to  slough,  often  over  a  large  area,  although  it  may  show  no  sign  of  the 
injury  received.     (See  page  68.) 

Lacerated  and  divided  muscles  should  be  adjusted  as  nearly  as  pos- 
sible in  their  normal  relations  and  may  be  secured  there  by  a  few  catgut 
sutures,  but  the  main  reliance  upon  their  proper  reunion  is  in  the  closing 
of  the  enveloping  fascia  over  them,  with  intervals  for  drainage.  Divided 
nerves  and  tendons  are,  of  course,  to  be  sutured,  and  torn  vessels  tied. 

The  proper  management  of  fragments  of  bone  is  often  a  matter  of 
anxious  doubt  and  the  surgeon  must  be  guided  somewhat  by  the  prob- 
ability of  avoiding  extensive  suppuration,  for  fragments  may  safely  be 
left  in  wounds  that  are  to  heal  kindly  which  must  certainly  be  removed 
sooner  or  later  if  suppuration  takes  place  about  them.  It  has  been 
abundantly  demonstrated  that  even  wholly  detached  fragments  can 
maintain  or  regain  their  vitality  and  be  an  important  aid  in  establish- 
ing: union  between  the  main  frag-nients  if  infection  is  avoided.  If  the 
loss  of  bone  is  considerable  it  is  advisable  to  square  the  ends  of  the 
main  fragments  and  bring  them  close  together;  in  the  leg  this  loss  is 
usually  at  the  expense  of  the  tibia,  and  the  fibula  must  then  be  corre- 
spondingly shortened. 

If  the  laceration  of  the  muscles  is  great,  and  persistent  infection 
probable,  abundant  provision  for  drainage  and  irrigation  should  be 
made.  Long  fenestrated  rubber  tubes  sliould  be  run  through  the  limb, 
by  counter-openings,  and  should  project  through  the  dressings  so  that 


126  FRACTURES. 

an  antiseptic  solution  can  be  frequently  injected  during  the  first  few 
days  or  until  the  infection  is  under  control.  If  suppuration  becomes 
fully  established  it  must  be  treated  according  to  general  principles,  or 
amputation  must  be  done. 

A  recent  substitution  of  iodine  for  other  antiseptics  has  seemed  to 
be  advantageous.  In  the  clean  cases  by  indirect  violence  the  interfer- 
ence is  limited  to  painting  the  skin  with  tincture  of  iodine;  in  dirty 
(infected)  cases  the  wound  is  thoroughly  washed  out  with  tincture  of 
iodine  in  salt  solution — one  drachm  to  the  pint;  if  suppuration  ensues 
the  wound  is  irrigated  with  a  solution  composed  of  tincture  of  iodine, 
1  part;  iodide  of  potassium,  2  parts;  guaiacol,  5  parts:  glycerine,  to 
100.  Drainage,  if  necessary,  is  made  with  rubber  tissue.  A  still  more 
recent  substitute,  hypochlorite  of  soda,  Dakin's  solution,  has  been 
largely  used  in  France  in  compound  gunshot  fractures  with  excellent 
results.  If  properly  made  it  is  unirritating,  but  if  its  alkalinity  is  not 
fully  corrected  it  harms  the  tissues.  When  active  infection  is  present 
it  should  be  used  freely  by  irrigation,  but  otherwise  it  is  sufficient  to 
keep  the  wound  constantly  wet  with  it  by  pouring  on  a  small  amount 
every  two  hours.  The  wounds  I  saw  at  Dr.  Carrel's  hospital  at 
Compiegne  under  this  treatment  were  in  perfect  condition,  but  those 
in  some  other  hospitals  looked  dry  and  dark,  presumably  because  of 
improper  preparation  of  the  solution.  After  complete  disinfection 
salt  solution  gives  equally  good  results.^ 

Gunshot  Fractures. 

Pistol-shot  fractures  of  civic  life  can  generally  be  successfully  treated 
by  a  single  irrigation  of  the  wound  and  an  antiseptic  dressing  without 

1  The  following  is  the  method  of  preparation  of  the  hypochlorite  solution  now  employed 
by  Dr.  Carrel: 

1.  Bleaching  powder  (chloride  of  lime)  (chemists  tell  me  that 
by  this  is  probably  meant  what  we  term  hypochlorite 

of  lime) 200  grammes 

Carbonate  of  soda,  dry 100  grammes 

Bicarbonate  of  soda SO  grammes 

2.  Put  the  bleaching  powder  (chloride  of  lime)  in  a  12-litre  flask  with  5  litres  of  ordinary 
water  and  let  it  stand  overnight. 

3.  Dissolve  the  carbonate  and  bicarbonate  of  soda  in  5  litres  of  ordinary  cold  water. 

4.  Pour  the  whole  of  the  carbonate  and  bicarbonate  solution  (3)  into  the  flask  containing 
the  maceration  of  chloride  of  lime  (2) ,  shake  it  vigorously  for  a  minute  and  let  it  stand  to 
permit  the  carbonate  of  lime  to  settle. 

5.  After  half  an  hour  siphon  off  the  clear  liquid  and  filter  it  through  paper  to  obtain  a 
perfectly  limpid  product;  this  must  be  kept  protected  from  the  light. 

The  antiseptic  solution  is  then  ready  for  surgical  use ;  it  contains  about  0.50  gr.  per 
cent,  hypochlorite  of  soda  with  small  amounts  of  neutral  soda  salts;  it  is  practically 
isotonic  with  blood  serum;  it  should  meet  the  following  test: 

Test. — Put  about  20  c.c.  of  the  solution  in  a  glass,  and  pour  upon  its  surface  a  few 
centigrammes  of  phenolphthalein  in  powder;  shake  it  with  a  circular  movement  as  in 
rinsing;  the  liquid  should  remain  colorless.  A  more  or  less  marked  red  discoloration 
indicates  the  presence  of  a  notable  quantity  of  free  alkali,  or  incomplete  carbonatioji, 
imputable  to  an  error  in  technic. 

Errors  to  he  Avoided. — Never  heat  the  solutions.  If  in  an  emergency  it  is  necessary  to 
triturate  the  chloride  of  lime  in  a  mortar,  do  so  only  with  water,  never  with  the  solution 
of  the  soda  salts. 

Titration. — To  10  c.c.  of  the  solution  add  10  c.c.  of  distilled  water,  2  grammes  of  iodide 
of  potassium,  and  2  c.c.  of  acetic  acid.  Pour  into  this  mixture  a  decinormal  (2.48  per  cent.) 
solution  of  hyposulphite  of  soda  until  it  is  decolorized.  The  number  of  c.c.  of  hypo- 
sulphite employed  multiplied  by  0.03725  equals  the  percentage  of  hypochlorite  of  soda 
in  the  solution.     See  also  Carrel:  Jour.  Amer.  Med.  Ass.,  vol.  Ixvii,  p.  1777. 


TREATMENT.  127 

removal  of  the  bullet.  It  is  very  rare  for  a  piece  of  the  clothing  to  be 
carried  in  beyond  the  skin.  When  the  missile  is  a  large  rifle  ball  or  a 
charge  of  shot  at  close  range  the  destruction  of  the  soft  parts  is  such 
that  prompt  closure  of  the  wound  cannot  be  expected,  and  the  case 
must  be  treated  as  one  of  the  second  class  just  described.  INIodern 
military  gunshot  fractures  are  usually  associated  with  extensive  com- 
minution of  the  bone  and,  in  Europe  at  least,  with  dangerous  infection. 
The  experience  of  the  present  war  is  interpreted  to  indicate  the  advis- 
ability of  free  enlargement  of  the  wound  and  drainage.  Loose  fragments 
should  be  picked  out,  but  every  effort  should  be  made  to  save  all 
others.  I  saw  at  least  a  dozen  limbs  in  the  military  hospitals  which 
were  practically  useless  because  of  the  failure  of  union  that  followed 
upon  the  removal  of  the  fragments.  Moderate  traction  should  be  made 
while  the  infection  is  being  combated,  but  afterward  the  gap  created 
by  loss  of  bone  must  be  measurably  closed  by  approximation  of  the 
main  fragments. 

Amputation. 

There  is  a  class  of  cases,  fortunately  not  a  large  one,  in  which  primary 
amputation  is  clearly  indicated,  cases  in  which  the  fracture  is  only 
one,  and  sometimes  not  the  most  important,  of  the  injuries  received. 
The  extensive  destruction  of  the  soft  parts,  sometimes  also  of  the 
bone,  makes  it  evident  that  the  limb  cannot  be  saved  or  that  if 
saved  it  would  be  useless.  The  only  question  is  as  to  the  time  and 
place  of  amputation.  I  am  confident  that  in  some  of  these  cases  a 
formal  amputation  well  above  the  injury  should  be  rejected  in  favor  of 
division  of  the  remaining  soft  parts  at  the  upper  limit  of  the  laceration 
and  the  removal  of  only  so  much  of  the  upper  fragment  as  can  be 
conveniently  reached  from  the  surface  of  section.  These  are  the  cases 
in  which  the  soft  parts  have  not  been  torn  and  bruised  above  the  line 
of  their  division,  and  in  which  it  is  important  to  save  as  much  as  pos- 
sible of  the  length  of  the  limb,  or  in  which  a  formal  amputation  would 
sacrifice  a  contiguous  joint,  especially  the  knee  or  elbow.  Recovery  of 
course  would  be  slower,  but  under  the  protection  of  asepsis  the  stumj) 
would  be  more  serviceable  than  those  which  were  formerly  obtained 
after  suppuration  and  whose  defects  led  to  the  rule  of  practice  which 
now,  I  think,  needs  revision.  Such  limited  experience  as  I  have  gained 
in  the  matter  encourages  me  to  invite  consideration  of  it. 

Doubt  as  to  the  advisability  of  amputation  and  anxiety  as  to  the 
result  if  amputation  is  not  done  arise  in  those  cases  in  which  the  injury 
is  not  clearly  destructive  of  the  limb  or  its  usefulness,  but  in  which 
the  attempt  to  save  it  will  imperil  life  by  the  progress  of  an  infection 
already  present  or  certain  to  result  from  the  sloughing  of  the  bruised 
tissues.  It  is  a  peculiarly  anxious  question  for  the  surgeon,  for  it 
involves  his  reputation  for  sound  judgment  as  well  as  the  welfare  of 
the  patient.  Weighing  the  probabilities  he  may  wisely  decide  that  the 
chance  of  saving  the  limb  or  of  its  usefulness  if  saved  is  not  such  as 
to  justify  the  taking  of  the  risks  involved  in  the  attempt  to  save  it,  and 


128  '  FRACTURES. 

yet  if  the  patient  refuses  amputation  and  happily  saves  both  life  and 
limb  the  advice  to  amputate  is  likely  often  to  be  recalled  as  a  reproach 
or  an  error  of  judgment.  In  some  cases  it  is  probable  that  under  the 
protection  of  antiseptics  the  decision  can  be  delayed  until  time  shall 
have  shown  the  full  extent  of  the  injury  and  the  ability  or  inability 
to  control  the  infection,  with  a  reasonable  expectation  that  a  later  am- 
putation, if  necessary,  will  still  be  in  time  to  save  life ;  but  in  other 
cases,  particularly  in  the  middle-aged  and  alcoholic  and  in  those  with 
diseased  organs  and  tissues,  the  infection  is  so  superior  to  the  organ- 
ism's power  of  resistance  that  if  it  is  allowed  to  become  fairly  estab- 
lished death  is  inevitable.  In  the  first  set  of  cases  the  surgeon  may 
fairly  place  the  responsibility  of  delay,  of  taking  the  chances,  upon  the 
patient  or  his  friends ;  in  the  latter  he  must  throw  the  whole  weight  of 
his  opinion  unreservedly  in  favor  of  immediate  amputation  unless  he 
is  forced  to  believe  that  even  that  will  be  unavailing.  An  infection  in 
a  middle-aged  patient  which  in  a  few  hours  has  produced  a  condition 
of  apathy  or  subdelirium,  with  brownish  discoloration  of  the  skin 
extending  rapidly  upward  and  a  dark  offensive  discharge  from  the 
wound,  cannot  be  arrested  by  amputation,  except  perhaps  when  it  has 
not  got  above  the  knee  or  elbow ;  but  one  which  is  marked  rather  by 
abundant  suppuration,  even  with  high  fever,  by  less  implication  of  the 
sensorium,  and  by  a  slower,  reddish,  boggy  oedema  of  the  parts  about 
and  above  the  wound  can  often  be  saved  by  amputation. 

An  interesting  analysis  of  one  hundred  and  thirty-seven  cases  of 
compound  fractures  of  long  bones  has  been  made  by  Klauber.^  Ninety 
were  by  direct,  forty-seven  by  indirect  violence.  Twenty-four  are 
classed  as  traumatic  amputations,  primarily  operated  upon  to  regularize 
the  stump — one  death  ;  fourteen  were  treated  by  primary  amputation — 
two  deaths ;  fifteen  treated  conservatively — three  deaths,  and  two  suc- 
cessful secondary  amputations  ;  average  length  of  treatment  one  hun- 
dred and  three  days. 

Compound  Articular  Fracture. 

In  these  cases  also  conservative  treatment  has  gained  much  additional 
ground  ;  the  outlook  and  details  vary,  as  in  fracture  of  the  shaft,  with 
the  character  and  extent  of  the  injury  to  the  soft  parts.  In  addition 
to  the  principles  governing  the  treatment  of  similar  fractures  of  the 
shaft  the  surgeon  has  also  to  consider  the  conditions  arising  from  the 
implication  of  the  joint,  especially  the  probability  of  the  extension 
of  suppuration  to  it  and  the  effect  upon  its  functions  of  such  sup- 
]niration  or  of  the  injury  itself.  If  the  wound  is  small  and  clean 
its  communication  with  the  joint  may  be  disregarded,  or,  at  the  most, 
drainage  of  the  joint  made  and  maintained  for  twenty-four  to  forty- 
eight  hours.  The  principle  in  any  case  of  moderate  or  extensive  lacera- 
tion and  contusion  of  the  soft  part,  in  which  the  attempt  is  made  to 
preserve  all  the  articular  portions  of  the  bone  and  the  functions  of  the 
joint,  is  to  protect  the  joint  by  drainage  against  the  consequences  of 

1  Klauber:  Beitrage  zur  klin.  Chir.,  vol.  xliii.,  p.  319. 


TREATMENT.  129 

primary  infection  and  against  later  infection  from  the  wound  itself  by 
assuring  the  early  escape  of  the  exudates  of  the  latter.  In  the  more 
severe  cases — laceration,  splintering  of  the  articular  end,  free  commu- 
nication between  the  wound  and  joint — drainage  may  be  made  directly 
through  the  wound  and  even  partial  excision  of  the  joint  may  be  done 
to  insure  its  thoroughness. 

The  probable  effect  of  the  injury  to  destroy  the  functions  of  the  joint 
raises  the  question  of  resection  with  a  view  to  restrict  the  loss.  The 
answer  varies  with  the  joint  and  to  some  extent  with  the  vocation  of 
the  patient,  for  at  some  joints  and  in  some  occupations  solidity  is  more 
useful  than  mobility  with  insufficient  control.  Thus,  at  the  knee  anchy- 
losis is  preferable; at  the  ankle  tlie  removal  of  the  nstrngalus  may  leave 
a  useful  limb,  but  anchylosis  is  better  than  removal  of  the  lower  portion 
of  the  tibia;  at  the  elbow  a  stiff  joint  in  a  good  position  is  more  useful 
than  one  that  is  very  loose  for  a  man  who  has  to  do  heavy  work,  while 
for  one  who  does  light  work,  using  mainly  his  fingers  and  wrist,  even 
a  loose  elbow  w^ould  be  better  than  a  stiff  one.  We  have  learned  too 
that  partial  resections  under  the  protection  of  the  antiseptic  method 
give  much  better  results  in  respect  of  mobility  than  they  formerly  did  ; 
thus,  removal  of  the  lower  end  of  the  humerus  with  conservation  of 
the  olecranon  gives  usually  a  more  useful  joint  than  total  resection 
does. 

GENERAL  TREATMENT. 

The  vital  indications  in  simple  fracture  of  the  limbs  rarely  arise 
except  in  the  aged  and  the  alcoholic.  In  the  former  the  shock  of  the 
injury,  frequently  a  fracture  of  the  neck  of  the  femur,  occasionally 
proves  fatal  within  a  day  or  two,  or  the  strength  gradually  fails  and 
the  patient  dies  about  the  third  week,  often  with  symptoms  of  localized 
pneumonia  at  the  end.  Against  this  there  is  little  that  can  be  done 
except  to  avoid  dressings  which  give  pain  and  increase  discomfort.  I 
do  not  believe  that  the  recumbent  posture  increases  the  latter  danger 
or  can  be  safely  discarded  during  the  first  three  weeks.  At  a  still 
later  period  it  may  sometimes  be  advisable,  because  of  the  general  con- 
dition, to  take  the  patient  out  of  bed  even  at  the  risk  of  failure  of  union. 

In  the  alcoholic,  it  is  important  to  maintain  nutrition  and  secure  sleep 
during  the  first  week,  and  to  give  alcohol  regularly  in  moderate  quan- 
tities;  it  is  claimed  that  the  chance  of  an  alcoholic  outbreak — delirium 
tremens — is  less  if  the  patient  is  not  kept  in  bed,  and  for  that  reason 
an  early  application  of  a  fixed  dressing  is  advised. 

No  medication,  except  tonics,  appears  to  have  any  value  in  hastening 
or  assuring  union  of  the  fracture  except  when  some  specific  poisoning 
is  present,  such  as  syphilis  or  paludism,  when  mercurials  and  quinine 
are  respectively  indicated. 


CHAPTEE  VIII. 

DELAYED    UNION,     FAILURE    OF    UNION,    PSEUDARTHROSIS, 

FAULTY  UNION.i 

Delayed  Union ;  Failure  of  Union. 

In  the  use  of  the  terms  delayed  unioii,  fibi'ous  union,  and  failure  of 
union  or  i^seudarthrosis,  a  certain  vagueness  of  differentiation  is  inevi- 
table because  of  the  frequent  lack  of  knowledge  of  the  exact  anatomical 
conditions  and  because  the  time  requisite  for  the  complete  repair  of 
a  fracture  varies  so  much  in  different  cases  that  it  may  not  be  pos- 
sible to  say  whether  in  a  given  case  the  process  has  come  to  a  standstill 
or  is  still  slowly  but  surely  continuing.  This  vagueness,  moreover,  is 
not  simply  clinical  but  extends  also  to  the  anatomical  condition,  for 
in  most  cases  this  represents  a  stage  through  which  the  process  of 
repair  commonly  passes,  that  of  union  of  the  fragments  by  a  bond  of 
fibrous  tissue,  and  the  abnormality  consists  in  the  delay  or  failure  of 
that  bond  to  ossify.  Furthermore,  as  this  final  step,  ossification,  is 
often  still  possible  after  a  delay  of  many  months,  a  case  which  fully 
deserves,  clinically,  to  be  termed  "failure  of  union,"  one  in  which 
special  measures  are  required  to  excite  ossification,  is  yet  identical, 
anatomically,  with  another  in  which  ossification  will  follow  without 
other  aid  than  the  prolongation  of  the  usual  immobilization.  The 
term  pseudarthrosis,  literally  false  joint,  is  not  restricted  to  those  rare 
cases  in  which  some  of  the  characteristic  anatomical  elements  of  a 
joint  are  present,  but  is  used  as  a  synonym  of  failure  of  union.  In 
cases  in  which  bony  union  is  from  the  first  unlooked  for,  or  has  been 
deemed  unlikely,  as  in  most  fractures  of  the  patella  without  operative 
treatment,  the  term  "  fibrous  union "  is  habitually  used  instead  of 
"  failure  of  imion." 

While  delay  in  union  is  not  infrequent,  failure  of  union  is  rare. 
The  published  statistics  of  failure  differ  so  widely  that  it  is  evident 
the  same  basis  of  classification  has  not  been  followed,  and  probably 
those  which  give  the  large  proportions  include  cases  of  delayed  union 
and  possibly  even  fractures  of  apophyses  which  are  habitually  so  dis- 
placed by  attached  muscles  that  only  fibrous  union  is  probable.  Fail- 
ure is  more  frequent,  actually  and  relatively,  in  the  shaft  of  the  humerus 
than  in  that  of  any  other  bone  (except  perhaps  the  radius  and  ulna), 
and  in  the  prime  of  life  than  at  any  other  age.  It  must  be  remembered 
that  these  statements  and  most  of  what  follows  relate  only  to  the  shafts 
of  the  long  bones,  and  do  not  include  fractures  of  the  short  bones,  of 
apophyses,  or  even  of  the  neck  of  the  femur.  Delayed  union  is  most 
frequent  in  the  leg  and  arm  ;  it  is  much  more  frequent  after  compound 

1  For  statistics  see  Norris:  American  Journal  of  the  Medical  Sciences,  1842,  vol. 
xxix.  Agnew's  Surgery,  vol.  i.  Gurlt:  die  Knoclienbriiche.  Berenger-Feraud : 
Traite,  des  fractures  non-consolid^es  ou  pseudarthroses,  1871.  For  experiniental 
study :  Cornil  and  Coudray,  Revue  de  Chir.,  24th  year,  No.  7. 

(  130  )  > 


DELAYED,   FAILURE,    OH  FAULTY  UNION.  131 

thau  after  simple  fracture.  According  to  Von  Bruns's  statistics 
delayed  union  occurs  in  about  1  \  per  cent,  of  fractures  of  the  shaft  of 
the  bones  of  the  limbs,  and  failure  of  union  in  about  half  of  1  per  cent. 

Pathology.  Although  the  anatomical  conditions  differ  greatly  in 
detail  they  may  be  conveniently  classified  in  two  groups,  one,  contain- 
ing most  of  the  cases,  in  which  the  fragments  ai'e  united  end  to  end  or 
laterally  and  more  or  less  closely  by  fibrous  tissue,  and  another,  very 
rare,  in  which  a  distinct  joint  has  formed  betAveen  them.  The  varie- 
ties of  the  first  form  are  very  numerous,  the  variations  depending  upon 
the  relative  positions  of  the  fragments,  the  extent  of  the  preliminary 
rarefaction,  the  amount  of  fibrous  tissue,  and  the  presence  or  absence 
of  a  productive  osteitis  or  partial  ossification  of  the  bond.  In  short, 
the  process  of  repair  in  any  of  the  widely  different  forms  imposed 
upon  it  by  the  character  of  the  fracture  and  the  displacement  may  be 
arrested  at  any  period  or  may  be  continued  unevenly  but  still  incom- 
pletely at  different  points.  Thus,  the  fragments  may  be  in  close  ap- 
position and  united  by  a  short  firm  bond  with  only  slight  motion 
between  them,  or  they  may  overlap  in  such  a  way  that  the  surfaces  of 
fracture  are  not  apposed  and  the  union  is  only  by  the  thickened  inter- 
posed connective  tissue  ;  or  the  displaced  end  may  be  enlarged,  with 
osteophytes  extending  into  the  fibrous  bond  and  separate  nodules  of 
bone  developed  within  it,  needing  only  a  slight  additional  ossification 
for  complete  bony  union  ;  or  the  effect  of  the  preliminary  rarefaction 
of  one  or  both  fragments  may  not  have  been  corrected  by  subsequent 
ossification,  and  they  remain  soft  and  spongy,  or  atrophied  and  pointed, 
and  even  this  process  of  rarefaction  may  be  so  exaggerated  as  to  create 
as  distinct  a  gap  between  the  fragments  as  if  a  piece  had  been  removed 
or  even  to  transform  the  entire  shaft  of  the  bone  into  a  fibrous  cord,  or, 
as  in  a  case  of  fracture  at  the  lower  end  of  the  humerus  reported  by 
Machol,^  to  cause  the  disappearance  of  the  epiphysis. 

Of  the  second  form,  the  creation  of  a  joint  between  the  fragments, 
only  a  few  examples  have  been  recorded.  They  show,  in  more  or  less 
complete  and  distorted  forms,  joints  with  a  fibrous  capsule  embedding 
cartilaginous  or  bony  nodules,  a  cavity  containing  a  synovia-like 
liquid,  and  the  ends  of  the  fragments  rounded,  eburnated,  usually 
enlarged,  sometimes  smooth  and  polished  and  sometimes  covered  with 
a  fibrous  or  even  a  cartilaginous  lining. 

Utiology.  Certain  general  conditions  have  been  deemed  a  cause  of 
delay  or  failure  of  union  either  through  a  specific  poison,  as  in  syphilis, 
or  through  a  deterioration  of  the  health  or  a  lowering  of  the  vitality 
induced  by  them,  as  pregnancy,  lactation,  defective  nourishment,  and 
acute  diseases ;  but  it  is  beyond  question  that  the  causes  are  usually 
local  and  that  the  most  conimon  one  is  a  faulty  relation  of  the  frag- 
ments to  each  other,  including  therein  the  interposition  betAveen  them 
of  muscular  tissue.  Others  are  defective  innervation,  disease  of  the 
bone,  inflammation  on  the  surface,  and  defective  treatment,  and  in 
compound  fracture  the  prolongation  of  suppuration  and  the  existence 
of  parcellary  necrosis  of  tlie  ends  of  the  fragments.  But  it  is  also 
true  that  delay  and  even   failure  may  occur  when  no  local  or  general 

1  Machol :  Centralb.  fiir  Chir.,  1904,  p.  1399. 


132  FRACTURES. 

cause  can  be  foimcl,  wlieu  the  fragments  are  in  exact  apposition, 
and  when  the  general  condition  is  good.  We  know  that  the  less  the 
primary  displacement,  the  more  exact  the  reposition,  and  the  more 
complete  the  immobilization,  the  less  is  the  local  reaction  and  the 
smaller  the  callus.  It  is  possible,  therefore,  that  the  reaction — the 
hypersemia  and  the  exaggeration  of  the  local  nutritive  processes — may 
be  too  slight  or  too  brief  to  complete  repair,  but  this  only  throws  the 
question  further  back,  and  we  have  yet  to  learn  why  the  reaction  is 
insufficient  in  one  case  and  sufficient  in  others  which  are  apparently 
identical.  In  a  few  compound  fractures  at  the  lower  end  of  the  leg 
and  of  the  arm  in  which  after  a  delay  of  two  or  three  months  I  have 
exposed  the  fragments  to  remove  a  sequestrum  or  for  readjustment,  I 
have  noticed  that  while  the  upper  fragment  was  richly  supplied  with 
blood  the  lower  one  was  pale  and  the  granulations  capping  it  soft  and 
scanty.  The  appearance  suggested  that  the  loss  of  the  blood  usually 
supplied  to  the  lower  fragment  by  the  nutrient  artery  might  sometimes 
leave  it  too  scantily  supplied  for  active  reparative  work.  Injury  of 
the  nutrient  artery  may  then  be  one  of  the  causes  of  delayed  union. 
In  the  leg  and  in  the  forearm  a  condition  occasionally  exists  which  is 
not  found  where  there  is  only  a  single  bone.  For  example,  the  fibula 
unites,  but  the  rarefactive  process  in  the  tibia  is  exaggerated  and  leaves 
the  fragments  separated  by  quite  an  interval  occupied  by  granulations, 
and  the  ossification  which  follows  is  not  active  enough  to  extend  entirely 
across  it.  If  the  bone  were  single  it  seems  not  unreasonable  to  sup- 
pose that  the  fragments  would  be  brought  nearer  together  and  the 
intermediate  granulations  stimulated  by  the  pressure  caused  by  the 
contraction  of  the  muscles,  but  here  the  fibula  holds  the  fragments 
apart.  This  exaggerated  rarefaction  can  sometimes  be  directly  observed 
in  compound  fractures,  especially  in  the  spongy  tissue  near  the  epiphy- 
ses. The  delay  commonly  observed  after  resection  for  the  relief  of 
pseudarthrosis  I  attribute  to  the  absence  of  a  periosteal  bridge  and  to 
the  stripping  back  of  the  periosteum  from  the  cut  end  of  the  bone. 

The  defective  relations  of  the  fragments  consist  mainly  in  a  dis- 
placement by  which  the  fractured  surfaces  are  more  or  less  widely  sep- 
arated and  which  is  maintained  perhaps  by  the  interposition  of  muscle. 
This  interposition,  which  has  occasionally  been  demonstrated  by  opera- 
tion, is  thought  by  some  to  be  by  far  the  most  common  cause  of  failure 
of  union,  but  in  the  present  lack  of  observations  the  opinion  must  be 
deemed  too  exclusive.  It  is  probable  that  when  interposition  occurs  it 
is  by  penetration  of  the  sharp  point  of  one  fragment  into  the  overlying 
muscle.  Another  form  of  defective  relations  is  constituted  by  the  inter- 
position of  a  fragment  wholly  or  partially  detached  or  by  the  loss,  in  a 
compound  fracture,  of  one  or  more  fragments  and  the  consequent  crea- 
tion of  a  considerable  gap. 

Delay  or  failure  in  compound  fracture  is  furthered  by  necrosis  of 
the  end  of  a  fragment.  If  the  sequestrum  is  large  it  creates  a  gap  ;  if 
it  is  small  and  lodged  amid  the  granulations  which  are  awaiting  ossifi- 


DELAYED,   FAILURE,    OR  FAULTY  UNION.  133 

catiou,  it  has  seemed  to  me  that  its  action  might  be  similar  to  that 
which  I  have  attributed  to  the  metallic  suture.  I  have  found  several 
such  small  imbedded  sequestra  amid  pale  granulations  in  exposing  old, 
long-delayed  compound  fractures.  It  seems,  too,  as  if  the  impulse  to  a 
productive,  ossifying,  process  was  lost  or  greatly  diminished  after  the 
lapse  of  the  time  usually  sufficient  to  repair,  and  it  is  well  known  that 
it  can  be  re-aroused  by  fresh  local  violence. 

Failure  by  defective  innervation,  as  shown  by  Bognaud,'  occurs 
when  the  trophic  nerves  or  nerve  centers  of  the  limb  are  injured. 
Motor  or  sensory  paralysis  without  injury  of  the  trophic  apparatus 
does  not  delay  union.  Bognaud  collected  six  cases  of  failure  of  union 
of  fracture  of  the  leg  with  paraplegia  due  to  injury  of  the  spinal  cord 
at  or  below  the  last  dorsal  vertebra,  while  in  others  in  which  the  paral- 
ysis was  incomplete  or  the  spine  was  injured  at  a  higher  point  union 
took  place. 

Local  diseases,  syphilis,  cancer,  etc.,  which  by  destroying  or  soften- 
ing the  bone  lead  to  "  spontaneous "  or  "  pathological "  fracture,  act 
in  like  manner  to  prevent  repair;  and  deep  suppuration  in  compound 
fracture,  which  is  usually  associated  with  necrosis,  is  a  frequent  cause 
of  delay  or  failure. 

The  presence  of  an  open  wound  exposing  a  fracture,  even  wdien  sup- 
puration is  slight  and  superficial,  I  have  observed  in  several  cases  to 
be  accompanied  by  marked  hypersemia  and  softening  of  the  bone  and 
by  great  delay  in  union  of  the  fracture  even  ^vdien  the  fragments  were 
in  exact  apposition. 

Defective  treatment  includes  the  failure  to  correct  the  displacements 
which  make  union  difficult  and  which  might  be  corrected,  to  secure 
immobility  and  maintain  it  for  a  sufficient  length  of  time,  and  possibly 
certain  errors  of  commission,  such  as  the  excessive  use  of  cold  upon 
the  limb.  Of  these,  frequent  movement  of  the  fragments  upon  each 
other  has  long  been  thought  to  be  a  potent  factor  in  delaying  union, 
but  recent  experience  in  treatment  by  brief  immobilization  and  frequent 
massage  suggests  a  revision  of  the  opinion. 

The  return  of  mobility  after  union  has  become  apparently  complete, 
and  even  after  the  patient  has  used  the  limb  for  some  time,  is  occasion- 
ally observed.  In  most  of  the  cases  probably  the  union  has  only  been 
fibrous,  although  close  and  firm,  and  has  slowly  yielded  under  use ;  but 
in  others,  in  which  there  is  no  reason  to  doubt  the  solidity  of  the  imion, 
the  cause  has  been  a  local  inflammation,  such  as  erysipelas,  or  an  ulcer, 
an  acute  febrile  disease,  or  scurvy. 

Symptoms.  The  persistence  of  abnormal  mobility  after  a  lapse  of 
a  period  that  is  usually  largely  sufficient  for  union  constitutes  "de- 
layed "  union  ;  the  merger  into  "  failure  of  union  "  is  a  matter  of 
opinion  rather  than  of  exact  definition.  If  the  position  of  the  frag- 
ments is  good  and  the  mobility  slight  the  condition  should  be  deemed 
merely  one  of  delay  for  a  much  longer  period  than  when  the  local 
relations  are  less  favorable,  and  the  usual  treatment  of  a  fracture 
should   be  continued  ;  the  instances  are  numerous  in  which   union   has 

'  Bognaud :  Sur  I'influence  de  quelques  lesions  du  systdme  nerveux  sur  la  formation 
du  cal,  Th^se  de  Paris,  1878. 


134  FRACTURES. 

finally  become  complete  after  the  lapse  of  several  months  and  without 
exceptional  measures.  On  the  other  hand,  failure  may  be  predicated 
even  before  the  usual  time  has  passed  if  the  position  of  the  fragments 
is  very  unfavorable  and  the  mobility  still  great. 

The  persistence  of  abnormal  mobility  is  the  pathognomonic  sign, 
but  it  is  occasionally  difficult  or  even  impossible  of  recognition  either 
because  it  is  very  slight  or  because  the  fracture  is  so  close  to  the  articular 
end  of  the  bone  that  the  mobility  is  masked  by  the  movements  at  the 
joint ;  under  such  circumstances  the  functional  disturbance  and  pain 
may  be  the  only  symptoms.  The  abnormal  mobility  may  be  slight  or 
very  free,  and  is  usually  painless  until  its  limits  are  approached  or 
reached. 

Functional  disturbances  vary  with  the  extent  of  mobility,  the  limb, 
and  the  amount  of  the  associated  muscular  degeneration  ;  it  ranges 
from  complete  disability  to  interference  so  slight  as  scarcely  to  be 
noticeable ;  in  one  of  my  own  cases,  a  compound  fracture,  the  patient 
preferred  amputation  of  the  leg  to  longer  delay,  and  others  have  sought 
in  amputation  relief  from  the  pain  of  the  mobility.  Others,  again,  are 
able  to  use  the  limb  with  the  aid  of  a  brace,  and  some  even  without  it. 
In  the  shaft  of  the  femur  the  disability  is  usually  the  greatest  and  is 
practically  complete,  but  when  at  its  neck  the  limb  may  be  still  quite 
useful ;  I  have  seen  several  such  cases. 

Treatment.  AVhen  delay  has  occurred  and  the  local  conditions  are 
such  that  union  may  reasonably  be  hoped  for,  the  surgeon's  first  duty 
is  to  seek  for  and  combat  any  general  condition  that  may  be  at  fault, 
such  as  syphilitic  or  malarial  poisoning  or  defective  nourishment,  using 
the  respective  remedies  and  tonics,  and  perhaps  giving  preference  among 
the  latter  to  phosphorus  or  phosphate  of  lime.  Then  he  continues  the 
immobilization,  aiding  it  then  or  a  little  later  by  massage;  this  still 
failing,  he  has  choice  of  a  number  of  mild  measures  to  hasten  the  proc- 
ess, such  as  the  application  for  a  few  hours,  once  or  twice  repeated,  of 
a  bandage  about  the  limb  above  the  fracture  tight  enough  to  cause 
venous  congestion  and  swelling  (Bier),  the  painting  of  the  skin  Avith 
iodine,  or  the  injection  of  a  few  drops  of  tincture  of  iodine  or  of  a  10  per 
cent,  solution  of  the  chloride  of  zinc  into  the  periosteum  and  the  fibrous 
bond  at  the  fracture ;  or,  in  the  case  of  the  leg,  if  the  mobility  is  slight 
and  the  fragment  in  good  position,  he  applies  a  splint  or  brace  by  the 
aid  of  which  the  limb  can  be  used  in  walking  without  too  much  risk 
of  causing  displacement,  in  the  hope  that  the  irritation  thereby  pro- 
duced at  the  fracture  may  stimulate  the  process.  Bier  (3Iedizinische 
Klinik,  1905,  Xo.  1)  recommends  the  hypodermic  injection  about  the 
fracture  of  30  c.cm.  of  blood  drawn  from  a  vein  of  the  patient. 

Some  interesting  experiments  with  the  method  are  reported  by  Hil- 
genreiner  (Bcitrdge  ziir  Min.  Chir.,  vol.  liv.,  p.  531). 

If  these  also  fail  or  if  the  condition  calls  for  more  pronounced  meas- 
ures, he  seeks  to  produce  a  sharp  reaction  by  forcibly  and  widely  bend- 
ing the  limb  at  the  fracture,  under  an  anaesthetic,  so  as  to  tear  the  bond 
and  measurably  produce  the  conditions  of  a  fresh  fracture,  or  he  passes 
a  drill  down  to  the  bone,  with  or  without  incision,  and  perforates  the 
ends  of  the  fragments  at  several  points.     Bone  and  ivory  pegs  haAe 


DELAYED,   FAILURE,   OR  FAULTY   UNION.  135 

been  inserted  into  holes  thus  made  and  withdrawn  after  a  few  days  or 
weeks,  but  apparently  with  no  advantage  over  simple  drillino;. 

Electroh'sis  has  also  been  used  with  advantage,  the  needle  being 
passed  into  the  bone  between  the  fragments,  and  so  have  the  a*-rays. 

Finally,  in  the  older  cases  in  which  a  radical  change  in  the  condition 
of  the  ends  of  the  bone  is  required,  the  case  must  be  treated  through  a 
free  incision.  It  is  to  be  borne  in  mind  that  the  natural  processes  of 
I'epair,  started  by  the  trauma,  have  run  their  course;  to  the  original 
preparatory  rarefaction  has  succeeded  condensation  of  the  bone,  and  a 
quiescent  condition  is  established.  The  problem  is  to  cause  a  renewal 
of  that  series  of  processes,  together  with,  if  necessary,  a  suitable  adjust- 
ment of  the  fragments.  This  can  be  done  only  in  part :  the  important 
periosteal  bridge  cannot  usually  be  created,  and  the  surgeon  must  be 
content  with  removal  of  some  of  the  sclerosed  bone  and  a  freshening  or 
wounding  of  the  rest  which  will  start  a  reaction  similar  to  that  following 
fracture.  And  in  addition  he  may  need  to  overcome  the  shortening 
of  an  overlap.  The  latter  can  be  done  by  forcible  traction  applied 
by  the  hands  or  pulleys  attached  to  the  lower  segment  of  the  limb,  or 
in  a  case  needing  great  force  by  a  canvas  strip  looped  on  the  end  of  the 
lower  fragment  (^Martin).  Or,  this  failing,  a  piece  may  be  cut  from  the 
end  of  each  fragment.  This  may  supply  sufficient  trauma  to  start  the 
reparative  process;  if  it  is  thought  not  to  be  sufficient,  the  medullary 
canal  of  each  fragment  should  be  reopened  if,  as  usual,  it  has  been 
closed  by  new  bone,  and  a  few  drill  holes  may  be  made  in  the  thickened 
ends  to  increase  the  reaction.  If  the  ends  thus  squared  can  be  brought 
to  rest  against  each  other  without  tendency  to  lateral  displacement 
nothing  more  is  needed  than  to  have  an  assistant  keep  them  in  place 
by  pressing  the  lower  segment  of  the  limb  forcibly  against  the  upper 
until  after  the  dressing  and  splints  have  been  applied.  Additional 
protection  may  be  given  by  sutures  in  the  overlying  or  adjoining  soft 
parts,  or  even  a  silk  or  absorbable  one  in  the  bone  as  a  guard  against 
displacement  during  the  dressing.  If  used,  this  should  be  tied  rather 
loosely  so  as  not  to  be  broken  by  the  moderate  angular  deviations  which 
are  almost  unavoidable  during  the  dressing.  I  have  given  reasons  in 
the  preceding  chapter  for  not  using  metal  sutures  or  pins  in  the  bone. 

It  is  unfortunately  the  fact  that  these  measures  frequently  fail  to 
procure  union  (von  Bruns  reports  203  failures  in  440  resections  of  the 
ends),  and  of  late  much  attention  has  been  given  to  Atlee's  bone 
inlay^  and  bone  medullary  pins,  described  in  the  preceding  cha])ter, 
and  a  much  larger  proportion  of  successes  has  followed.  ]Murphy- 
specially  recommends  the   medullary  pin. 

When  failure  of  union  has  been  due  to  loss  of  bone  the  gap  has 
sometimes  been  filled  and  union  obtained  by  pieces  of  fresh  or  decalci- 
fied bone  over  which  the  soft  parts  are  closed  by  primary  healing. 
Absolute  asepsis  is  necessary  to  success.  Apparently  the  pieces  act 
only  mechanically  by  furnishing  a  framework  within  and  around  which 

1  Atlee:  Am.  Journ.  Surg.,  January,  1914. 

2  Jour.  Am.  Med.  Assn.,  April  13,  1912,  p.  lOO.j;  and  Surg.,  Gyii.  and  Obst.,  vol.  xvi. 


136  FRACTURES. 

the  granulations  grow  and  by  filling  the  space  which  if  left  to  be  filled 
by  the  slowly  forming  granulations  would  collect  the  exudates  and  thus 
favor  the  spread  of  chance  infection.  Bone  grafting  has  been  done 
with  some  success,  especially  in  gunshot  fractures  of  the  jaw  with 
much  loss  of  substance. 

When  loss  of  substance  has  occurred  in  one  of  two  parallel  bones,  as 
in  tlie  leg  or  forearm,  it  is  usually  advisable,  if  the  gap  is  not  too  large, 
to  excise  a  corresponding  piece  from  the  other  bone  so  that  the  frag- 
ments of  the  first  can  be  brought  into  contact.  When  the  gap  has  been 
larger  in  the  tibia  a  solid  limb  has  been  obtained  by  dividing  the  fibula 
and  uniting  its  lower  segment  with  the  upper  segment  of  the  tibia.  In 
time  the  bone  enlarges  sufficiently  to  make  the  limb  strong  and  useful. 

Faulty  or  Vicious  Union  ;  Union  with  Deformity. 

The  use  of  these  terms  is  restricted  to  cases  in  which  the  deformity 
or  persistent  displacement  differs  notably  from  the  result  usually 
obtained  after  that  form  of  fracture ;  the  term  is  not  applied  when  the 
irregularity  is  slight  or  common.  Thus  it  is  not  applied  to  moderate 
shortening  by  overriding  in  oblique  fractures,  to  the  shortening  and  out- 
ward rotation  commonly  seen  after  fracture  of  the  neck  of  the  femur, 
or  to  the  deformity  of  the  wrist  so  frequently  seen  after  Colles's  fracture. 
In  short,  its  use  implies  a  marked  condition  that  might  and  should  have 
been  avoided. 

Any  of  the  possible  displacements  after  fracture  may  remain  uncor- 
rected and  produce  this  condition,  but  the  most  common  are  marked 
angular  displacement  or  rotation  after  fracture  of  the  shaft  and  trans- 
verse displacement  with  overriding.  Excessive  size  of  the  callus  is 
sometimes  included  in  this  group  and  so  is  the  inclusion  in  the  callus 
of  muscle,  tendon,  or  nerve.  The  ill  results  are  not  limited  to  the 
change  in  the  appearance  of  the  limb,  which  is  often  marked  and 
offensive,  but  include  also  an  interference  with  function,  which  may 
amount  to  complete  disability  by  shortening  of  the  limb,  by  the  devia- 
tion of  its  lower  segment,  or  by  restricting  the  movements  of  a  neigh- 
boring joint  either  directly  or  indirectly  by  implication  of  its  muscles. 
Thus  angular  displacement,  with  or  without  overriding,  after  fracture 
of  the  thigh  near  the  middle  may  produce  a  shortening  of  several 
inches ;  angular  displacement  after  fracture  of  the  leg  may  so  raise  the 
heel  or  toes  or  invert  or  evert  the  foot  as  to  make  it  difficult  or  impos- 
sible to  place  the  sole  squarely  on  the  ground  in  walking  ;  transverse 
displacement  backward  or  forward  close  above  the  elbow  may  limit 
flexion  or  extension  respectively,  more,  I  think,  by  cicatricial  implica- 
tion of  the  muscle  than  by  contact  with  the  bones  of  the  forearm. 

Treatment.  The  method  of  treatment  varies  with  the  solidity  of 
union,  and  therefore  to  some  extent  with  the  length  of  time  that  has 
elapsed.  As  persistent  displacement  is  often  a  cause  of  delay  of  union 
and  of  early  weakness  of  the  callus,  it  is  possible  to  correct  the  posi- 
tion by  the  hands  alone  at  a  much  later  period  than  under  better  con- 
ditions ;  that  is,  an  angular  displacement  can  thus  be  corrected  by 
forcibly  straightening  the  limb  with  the  hands  or  with  the  knee  pressed 


DELAYED,   FAILURE,   OR  FAULTY  JJNION.  137 

against  the  projecting  angle.  But  little  improvement  in  overriding  is 
to  be  expected  from  such  means  because  the  cicatricial  condition  of  the 
soft  parts  which  maintains  it  cannot  often  thus  be  modified.  A  few 
cases  have  been  reported  in  which  continuous  traction  has  been  quite 
efficient.  Gradual  straightening  has  occasionally  been  effected  by  a 
lateral  brace  with  transverse  elastic  pressure  at  the  angle. 

Refracture  by  specially  devised  osteoclasts  has  been  miich  employed 
in  the  past  for  the  correction  of  angular  deformity,  but  has  largely 
given  place  of  late  to  open  operation.  Some  of  the  instruments  are 
very  powerful  and  accurate  in  the  application  of  the  force.  Union 
after  early  refracture  may  be  confidently  expected  to  require  less  time 
than  after  primary  fracture.  A  serious  obstacle  to  success  may  exist 
in  the  permanent  retraction  of  the  soft  parts  on  the  concave  side  when 
the  deformity  has  long  existed.  The  condition  then  resembles  that  of 
a  bent  bow,  and  as  the  length  of  the  soft  parts  determines  that  of  the 
limb  the  latter  cannot  be  increased,  and  the  bone  can  be  straightened 
after  breaking  it  only  by  forcing  the  ends  of  the  fragments  past  each 
other,  overriding. 

Osteotomy  meets  the  indications  in  the  same  manner  as  osteoclasis, 
but  more  widely  and  precisely,  for  it  not  only  insures  division  at  the 
chosen  point,  but  it  also  permits  the  correction  of  lateral  displacement 
and  the  removal  of  a  V-shaped  or  longer  piece  if  the  condition  is 
that  mentioned  at  the  close  of  the  preceding  paragraph.  With  strict 
attention  to  asepsis  recovery  is  likely  to  be  as  uneventful  as  after 
osteoclasis,  but  it  will  be  notably  slower  if  bone  is  excised.  Unless 
anatomical  reasons  to  the  contrary  exist  the  incision  should  be  made 
longitudinally  at  or  near  the  most  projecting  part  of  the  bone,  and 
should  be  long  enough  to  permit  free  exposure  and  easy  access  to  it ; 
the  management  of  the  bone  will  be  determined  by  the  relations  of 
the  fragments  and  by  the  end  in  view,  but  in  case  of  excision  every 
effort  should  be  made  to  maintain  the  continuity  of  the  periosteum  on 
one  side  and  to  restore  it  by  suture  on  the  other  at  the  end  of  the 
operation. 

In  articular  fracture  with  displacement,  such  as  an  uncorrected 
Pott's  fracture,  the  bone  can  sometimes  be  restored  to  place  by  open 
operation  with  considerable  improvement  in  function.  I  have  im- 
proved the  condition  in  a  number  of  Pott's  fractures  in  this  way; 
and  in  one  of  accidental  fracture  of  the  outer  condyle  of  the  humerus 
in  which  the  primary  fracture  (two  years  previous)  had  resulted  in 
considerable  limitation  of  motion,  I  exposed  the  fracture  by  incision 
because  of  non-reducible  displacement  of  the  fragment,  and  was  able 
so  to  place  it  that  the  range  of  motion  was  subsequently  increased. 
Possibly  a  like  advantage  could  be  gained  by  a  deliberate  osteotomy 
and  shifting  of  the  fragments. 

An  excessive  portion  of  callus  or  a  projecting  fragment  which  causes 
pain  or  ulceration  of  the  skin  by  pressure  can  be  removed  by  the  chisel 
or  rongeur. 
10 


CHAPTER  IX. 

GENERAL  PEOGNOSIS. 

The  prognosis  after  fracture  involves  consideration  of  the  effects  of 
the  injury  in  respect  of  the  prolongation  of  life,  the  preservation  of  the 
limb,  its  usefulness  if  preserved,  and  the  time  required  for  recovery. 
The  factors  in  the  prognosis  have  been  considered  in  detail  in  the  pre- 
ceding chapters  and  will  only  be  grouped  here  for  a  more  convenient 
general  review. 

The  prognosis  varies  with  the  age  and  condition  of  the  patient,  the 
position  and  character  of  the  fracture,  and  the  complications  present  or 
possible. 

The  Patient.  Sex  does  not  affect  the  prognosis.  Age  has  a  con- 
siderable influence ;  the  younger  the  patient  the  better  the  prognosis, 
because  in  the  young  fractures  unite  more  easily  and  promptly  than 
in  the  adult,  and  advancing  years  increase  the  probability  of  dimin- 
ished vitality  and  of  the  presence  of  constitutional  dyscrasise.  In  the 
old  the  prognosis  is  worse  in  respect  of  life  because  of  their  diminished 
ability  to  withstand  the  shock  and  to  bear  prolonged  confinement  to 
bed  and  pain,  and  worst  in  respect  of  function  because  of  the  greater 
difficulty  with  which  the  affected  soft  parts  and  joints  regain  their 
original  conditions.  The  reduction  of  vitality  by  degeneration  or  dis- 
ease of  various  organs  may  have  a  similar  effect.  Chronic  alcoholism 
exposes  to  an  outbreak  of  delirium  tremens  and,  as  does  also  advanced 
age,  to  the  so-called  hypostatic  pneumonias. 

Sudden  death  by  fat  or  jmhnonary  embolism  is  possible,  but  very 
rare,  at  any  age  and  with  almost  any  form  of  fracture. 

The  Fracture.  In  compound  fracture  the  prognosis  is  worse  in  every 
respect  than  in  simple  fracture,  and  worse  when  by  direct  violence  than 
by  indirect  violence  because  of  the  usually  greater  extent  and  severity 
of  the  associated  lesions  of  the  soft  parts. 

The  fracture  of  the  shaft  of  a  long  bone  generally  heals  with  some 
shortening,  the  chief  exceptions  being  the  incomplete  and  subperiosteal 
fractures  of  the  young  and  transverse  fractures  in  which  lateral  and 
angular  displacements  can  be  reduced  or  prevented. 

Fractures  of  the  short  or  spongy  bones  heal  promptly,  but  the  dis- 
placement, with  or  without  crushing,  cannot  usually  be  fully  corrected. 
Fracture  of  the  spongy  end  of  a  long  bone  usually  heals  more  quickly 
than  fracture  of  the  shaft,  but  occasionally  delay,  or  even  failure  of 
union,  is  occasioned  by  exaggeration  of  the  preliminary  rarefactive 
process.  Fracture  of  a  flat  bone  is  rather  frequently  followed  by 
exaggerated  formation  of  callus. 

Fracture  of  one  of  two  parallel  and  connected  bones  (leg,  forearm) 
is  more  easily  managed  and  lias  a  better  prognosis  than  fracture  of  both 
(138) 


GENERAL  PROGNOSIS.  139 

or  of  a  single  bone,  because  the  unbroken  one  acts  as  a  splint;  an 
exception  to  this  is  found  when  the  fracture  is  accompanied  by  a  loss 
of  substance  which  creates  a  gap  between  the  fragments. 

Articular  fractures  and  fractures  near  the  joints  are  especially  liable 
to  be  followed  by  limitation  of  motion  in  the  joint ;  at  the  knee  and 
elbow,  and  to  a  less  extent  the  shoulder  and  hip,  this  is  the  rule. 

No  general  statement  of  value  can  be  made  as  to  the  time  required 
to  reach  the  final  result  after  fracture  or  as  to  tlie  completeness  of  resto- 
ration of  function,  and  the  statistics  that  have  been  collected  are  prac- 
tically valueless  because  they  do  not  completely  discriminate  between 
the  different  forms  and  ages  of  the  patients.  Each  fracture  or  at  least 
each  class  of  fracture  must  be  judged  by  itself,  and  in  many  a  given 
case  there  can  be  no  great  certainty  that  it  will  not  vary  widely  from 
the  average.  As  I  write  this  paragra]>h,  I  have  just  visited  a  patient 
who  broke  the  outer  portion  of  the  head  of  the  tibia  seven  months  ago  ; 
I  predicted  great  loss  of  motion  and  was  gratified  when  at  the  end  of 
about  four  months  a  range  of  45°  had  been  obtained,  and  yet  within 
the  last  two  months  that  range  has  been  increased  to  90°  under  natural 
use  of  the  limb.  I  think  it  can  properly  be  said  that  an  uncompli- 
cated fracture  of  the  shaft  of  the  long  bone  of  the  arm,  forearm,  or 
leg  will,  in  the  great  majority  of  cases,  heal  without  any  diminution  of 
the  earning  capacity  of  the  patient  after  six  months,  and  that  almost 
all  the  remainder  will  have  reached  the  same  condition  in  a  year.  In 
fractures  of  the  shaft  of  the  femur  more  time  is  required,  and  the 
number  of  those  who  will  remain  more  or  less  disabled  is  greater.  As 
middle  life  is  passed,  the  ability  of  the  patient  to  adapt  himself  to 
changed  conditions  is  less,  the  joints  are  more  likely  to  be  stiffened, 
and  pain  in  the  limb  after  fatigue  or  when  the  weather  is  cold  and 
damp  is  more  common.  Among  the  statistics  I  have  seen  are  those  of 
Loew  ^  and  Ramsperger,^  collected  from  the  records  of  Aid  Societies. 
Loew's  were  of  167  simple  fractures  of  the  leg;  only  one  was  perma- 
nently disabled,  the  others  regained  their  earning  capacity  in  an  average 
of  101  days,  70  per  cent,  in  91  days  each. 

Ramsperger's,  of  145  fractures  of  the  leg,  given  in  more  detail, 
show  complete  earning  capacity,  after  simple  fracture  of  the  shaft 
of  both  bones  healed  'without  deformity,  restored  in  most  during  the 
first  six  months,  in  a  few  not  until  the  third  or  fourth  year  ;  in  those 
that  healed  with  deformity  (36  per  cent.)  the  restoration  was  complete 
in  29  per  cent.,  in  the  remainder  the  loss  was  generally  less  than  25 
per  cent.  Of  the  compound  fractures  of  the  shaft  complete  restora- 
tion followed  in  32  per  cent.,  the  loss  in  the  remainder  was  usually  less 
than  25  per  cent. 

Of  the  simple  fractures  of  tlie  malleoli  there  was  recovery  without 
deformity  in  61  per  cent.,  with  deformity  in  39  per  cent. ;  of  the 
former,  restoration  was  complete  in  75  per  cent.,  of  the  latter,  in  23  ])er 
cent.  Two-thirds  of  all  resumed  work  during  the  first  six  months, 
one-third  during  the  second  six  months.  After  compound  fracture 
there  was  always  some  loss. 

1  Loew :  Deutsche,  Zeitschrift  f.  Chir.  vol.  xliv.    Abstr.  in  Centralb.  f.  Cliir.,  1897.  p.  8.55. 
'^  Eamspergei- :  Korresp.  des  Wiirtenib.  iirzt.  Laiidesvereins.     Abstr.  in  Centralb.,  1897» 
p.  735.     See  also  Morian  :  Arch.  klin.  Chir.,  vol.  81,  ii.  p.  98, 


140  FRACTURES. 

After  fractures  of  the  fibula  restoration  was  always  complete,  but 
sometimes  much  delayed. 

Sauer^  in  111  cases  of  fracture  of  one  or  both  bones  of  the  leg  or  of 
one  or  both  malleoli  (Pott's),  found  complete  restoration  of  earning 
capacity  in  75  per  cent,  after  16.4  months.  The  percentage  varied 
from  nearly  100  in  patients  under  twenty  years  of  age  to  about  33  per 
cent,  in  those  over  fifty  years. 

All  these  statistics  are  taken  from  the  records  of  relief  associations, 
the  patients  receiving  aid  according  to  the  degree  and  continuation  of 
the  disability. 

A  painstaking  and  valuable  study  of  the  late  results  after  fracture 
of  the  thigh,  based  on  a  hospital  service  of  three  years  was  made  by 
Ashhiu-st  and  Newell. ^  Of  19  elderly  and  2  young  patients  with  fracture 
of  the  neck  of  the  femur  13  had  entirely  useful  limbs,  6  walked  with  a 
decided  limp  (some  using  a  cane  or  crutch)  and  2  were  incapaciated. 
Of  31  fractures  of  the  shaft  19  had  a  perfect  functional  result,  10  a 
limp  but  no  disability,  and  2  (subtrochanteric  fracture  with  2  inches 
shortening)  marked  impahment.  Nine  fractures  of  the  condyles  gave  4 
perfect  functional  results,  3  wdth  limp  but  no  disability,  and  2  inca- 
pacitated. A  later  report^  on  40  cases  of  fracture  of  the  shaft  of  the 
femur  showed  a  perfect  result  in  60  per  cent.,  and  in  32  per  cent,  "no 
disability  other  than  a  slight  limp." 

From  the  elaborate  report  of  the  Committee  on  Fractures  of  the 
American  Surgical  Association  (Trans.,  1915)  I  take  the  following: 
Table  XXII.  196  fractures  of  the  shaft  of  the  femur  gave  133  good 
results,  31  moderate  and  22  bad.^  Of  these  77  were  under  fifteen  years 
of  age,  with  66  good,  6  moderate,  and  5  bad  results.  In  those  over 
fifteen  years  the  older  the  patient  the  poorer  the  result. 

In  fractures  of  all  regions,  "in  patients  under  fifteen  years  of  age 
good  functional  results  depend  less  upon  good  anatomical  results 
(exact  reposition)  than  in  older  patients.  The  older  the  patients  the 
greater  is  the  proportion  of  poor  results." 

In  patients  over  fifteen  years  of  age  the  proportion  of  good  functional 
results  was  "very  much  higher"  in  non-operated  than  in  operated 
cases. 

The  average  period  of  time  lost  from  work  after  simple  fractures  was: 

Shaft  of  humerus 14.0    weeks 

Head  and  neck  of  humerus 11.5 

At  condyles 9.0        " 

Both  bones  of  forearm     .      .    ■ 10.8 

Femur,  all  sites 7 .  37  months 

Leg 4.75       " 

1  Sauer:  Beitrage  zur  klin.  Chir.,  vol.  46,  p.  184. 

2  Ashhurst  and  Newell:  Annals  of  Surgery,  1908,  vol.  48,  p.  748. 

3  Ashhurst:  Annals  of  Surgery,  1911,  vol.  53,  p.  588. 

*  "Functional  results  are  considered  good  only  when  no  disability  exists  as  to  the  part 
affected.  If  there  is  pain  in  damp  weather,  even  though  the  patient  resumes  his  former 
job,  the  function  is  classed  as  moderate.  If  the  patient's  earning  capacity  is  notably 
diminished  as  a  consequence  of  the  fracture  the  functional  result  is  classed  as  bad;  this 
may  be  the  case  if  a  stiff  but  painless  joint  incapacitates  a  man.  Again,  the  function  of 
joint  or  limb  may  be  bad  without  disabling  its  possessor:  such  a  result  is  classed 
as  moderate." 


GENERAL  PROGNOSIS.  141 

Dr.  S.  P.  Martin^  draws  a  somewhat  darker  picture  after  examination 
of  198  fractures  of  the  shaft  of  the  femur  followed  up  and  42  fatal 
cases  out  of  400  received  in  seven  Philadelphia  hospitals.  As  his  single 
tabulation  deals  only  with  shortening  the  reader  is  referred  to  his 
paper.  Two  interesting  papers  by  Dr.  Steinke  and  Dr.  John  in  the 
end-results  after  fracture  of  the  femur  and  of  both  bones  of  the  leg 
respectively,  given  with  much  detail,  are  printed  in  the  Annals  of 
Surgery,  November,  1915. 

1  Martin:  Surg.,  Gyn.  and  Obst.,  vol.  xxi.,  p.  727. 


CHAPTER   X. 

FRACTURES   OF   THE  SKULL. 

The  function  of  the  cranium  is  so  largely  limited  to  mechanical 
protection  of  the  brain  and  its  annexa  from  external  violence,  its  frac- 
ture in  a  great  majority  of  cases  involves  after  recovery  so  slight  an 
interference  with  this  function,  and  treatment  can  do  so  little  to  dimin- 
ish this  interference,  that  the  importance  of  the  injury  lies  almost 
wholly  in  the  associated  injury  of  the  brain  and  in  the  later  inflam- 
matory or  degenerative  processes  therein  to  v.hich  that  injury  or  that 
of  the  overlying  soft  parts  may  give  rise,  and  its  consideration  falls  in 
the  majority  of  cases  rather  under  the  rubric  of  injury  of  the  brain 
than  under  that  of  fractures.  It  is  unfortunate  that  these  injuries 
should  be  so  universally  classed  as  fractures,  for  this  leads  to  an 
undue  fixing  of  the  atiention  upon  the  lesion  of  the  bone  to  the  exclu- 
sion or  minimizing  of  that  of  the  brain  and  to  undeserved  reproach  for 
occasional  failure  to  recognize  the  presence  of  fracture.  It  should  be 
remembered  that  the  violence  which  causes  fatal  injury  of  the  brain 
together  with  fracture  of  the  skull  may,  under  slightly  changed  con- 
ditions, cause  the  former  without  the  latter,  and  that  in  a  large  propor- 
tion of  fatal  cases  the  fracture  is  merely  an  incident  without  any  direct 
relation  to  the  fatal  result  or  only  with  that  of  having  made  the  causa- 
tive lesion  possible.  On  the  other  hand,  there  is  a  class  of  fractures 
in  which  the  lesions  are  entirely  local  and  limited  to  the  bone  and  the 
overlying  soft  parts,  or  in  which,  if  the  contents  of  the  cranium  are  at 
all  injured,  the  injury  is  limited  to  the  immediate  neighborhood  of  the 
fracture.  In  these  the  fracture  is  the  essential  lesion,  and  the  treatment 
is  almost  wholly  directed  to  it.  Between  these  two  forms — generalized 
contusion  of  the  brain  and  its  envelopes,  with  or  without  fracture,  and 
circumscribed  fracture  with  or  without  localized  injury  of  the  brain  or 
meninges — there  are  others  in  which  the  character  of  the  fracture  and 
its  mode  of  production  are  exaggerations  of  those  of  the  second  group, 
and  the  eflFect  upon  the  contents  of  the  cranium  those  of  t!ie  first  group. 
In  the  first  group  the  fracture  is  usually  fissured  and  almost  always 
occupies  or  extends  to  the  base  of  the  skull,  and  hemorrhages  covering 
a  large  area  though  limited  in  amount  of  extravasated  blood  are  found 
upon  the  surface  of  the  brain  and  sometimes  within  it  and  the  medulla, 
indicating  contusion  ;  in  the  second  the  type  is  a  compound  circum- 
scribed depressed  fracture,  possibly  with  a  rent  in  the  underlying  dura  ; 
in  the  intermediate  class  there  are  the  comminution  of  the  second  (but 
more  extensive  and  associated  with  fissure)  and  the  hemorrhages  and 
the  contusion  of  the  first.  In  the  production  of  the  first  the  causative 
violence  acts  broadly  upon  the  skull,  modifying  its  shape  tli rough  its 
elasticity  and  perhaps  splitting  it  by  exceeding  the  limits  of  that  elas- 
(142) 


FBAQTURES  OF  THE  SKULL.  143 

ticity,  and  bruising  its  contents  by  that  modification  of  the  shape  and 
by  the  jar,  as  in  a  fall ;  in  the  second,  as  in  a  blow  of  a  hammer,  the 
force  is  consumed  in  breaking  the  bone  at  the  }3oint  of  impact,  there  is 
no  general  change  in  the  shape  of  the  skull,  no  diffused  effect  upon 
the  brain  as  a  whole.  Because  of  the  mode  of  production  fractures  of 
the  second  group  are  usually  compound.  In  the  intermediate  group 
the  violence  is  greater  than  in  the  others,  it  breaks  a  larger  area  of 
bone  and  is  not  exhausted  in  producing  the  fracture.  This  difference 
in  the  mode  of  production  and  in  the  effects  of  the  violence  dominates 
the  whole  subject  and  determines  the  treatment  and  the  prognosis. 
All  this  appears  plainly  in  study  of  the  mechanism,  pathology,  and 
cause  of  the  injury  in  the  various  forms. 

Mechanism  and  Pathology. 

In  studying  the  mechanism  of  fracture  certain  anatomical  features 
of  the  cranium  must  be  borne  in  mind.  Of  the  vault  and  base  of 
which  it  is  composed  in  unequal  parts,  the  former  is  globular,  thick, 
and  elastic  ;  the  latter  is  flattened,  irregular,  thick  in  places,  thin  in 
others,  and  perforated  at  many  points  for  the  passage  of  nerves  and 
vessels.  From  the  occipital  condyles,  by  which  it  rests  upon  the 
spinal  column,  pass  outward,  backward,  and  forward  various  thick 
portions  or  ridges  constituting  a  strong  framework  to  connect  them 
with  the  vault  ;  the  basilar  process  and  body  of  the  sphenoid,  the 
occipital  crest,  and  tlie  petrous  portions  of  the  temporal  bones;  further 
forward  are  the  thicker  portions  of  the  greater  and  lesser  wings  of  the 
sphenoid  and  the  frontal  crest.  To  a  certain  extent  these  ridges  direct 
lines  of  fracture  of  the  base  to  the  thinner  intermediate  segments,  but 

Fig.  71. 


Sword  cut ;  fissured  fracture.     (Konig.) 


all  can  be  crossed  by  them.  The  vault,  Avhich  varies  greatly  in  thick- 
ness at  different  points  and  in  different  individuals,  has  a  thick  outer 
and  a  thin  inner  table  of  den.se  bone  ."eparated  by  the  spongy  di])l()r'. 
The  physical  characteristic  of  the  vault  which  most  concerns  us  is  its 


144 


FRACTURES. 


Fig.  72. 


elasticit}^  which  is  sufficient  to  permit  a  considerable  change  of  shape 
without  fracture — that  is,  a  diameter  of  the  skull  can  be  shortened  and 
those  at  right  angles  to  it  lengthened  by  compressing  it  in  a  vise,  or  a 
portion  of  its  surface  can  be  momentarily  flattened  by  a  blow. 

The  effect  of  violence  acting  upon  the  skull  varies  with  its  character 
and  the  size  and  shape  of  the  vulnerant  body,  and  appears  in  all  the 
gradations  between  a  slight  crush  or  cut  of  the  outer  table  or  of  the 
entire  thickness  of  the  bone,  through  circumscribed  depressed  areas 
to  single  or  multiple  fissures  running  completely  around.  A  cutting 
instrument,  as  a  chisel  or  sword,  cuts  partly  or  entirely  through  the 
bone  and  by  its  wedge-action  may  produce  long  fissures  running  from 
each  end  of  the  cut  if  the  weapon  is  heavy  and  the  blow  powerful 
(Fig.  71),  or,  if  the  instrument  changes  its  direction,  it  may  break  off 
a  piece  of  the  bone  and  raise  it  above  the  level. 

A  moderate  blow  with  a  pointed  or  edged  weapon  may  simply  break 
the  outer  table,  where  the  bone  is  thick,  and  depress  it  by  crushing  the 
underlying  diploe,  or,  if  the  bone  is  thin,  it  may  make  a  small  rounded 
hole  in  it  without  splintering  or  fissuring  of  the  side.  If  the  instru- 
ment is  not  sharp  or  edged  the  bone  is  bent  inward  and  the  effect  varies 
with  the  force  of  the  blow  and  the  prolongation  of  its  action.  In  the 
slightest  form  the  elasticity  of  the  skull  takes  up  and  distributes  the 
force  without  recognizable  injury  to  the  bone.  If  the  force  is  a  little 
greater  the  inner  table,  which  is  overbent  in  the  movement,  splits  away 

from  the  diploe  and  is  broken  (frac- 
ture of  the  inner  table  alone),  the 
unbroken  portion  springing  back  to 
its  original  position  and  leaving  the 
fragment  more  or  less  removed  and 
changed  in  position.  The  same  effect 
has  been  produced  in  the  outer  table 
by  a  blow  from  within,  as  by  a  bullet 
that  has  traversed  the  skull  from  the 
opposite  side. 

If  the  force  is  still  greater  the 
bone  is  broken  entirely  through  to 
an  extent  and  in  directions  that  vary 
widely,  and  the  circumscribed  por- 
tion remains  more  or  less  depressed. 
If  the  lines  of  fracture  do  not  en- 
tirely circumscribe  the  affected  area  the  elasticity  of  the  unbroken 
portion  brings  back  the  depressed  piece  toward  or  to  its  place  (Fig. 
73),  sometimes  imprisoning  in  the  fissure  a  few  hairs  or  a  portion  of 
the  head  covering.  If  the  circle  of  fracture  is  complete  the  enclosed 
portion  remains  depressed,  either  bodily  or,  more  commonly,  with 
sloping  sides  (Fig.  74).  From  the  edge  of  the  opening,  small  fissures 
or  circumscribed  lines  of  fracture  frequently  run.  The  inner  table  is 
always  more  extensively  broken  than  the  outer  one,  and  the  two  are 
largely  separated  from  each  other  by  planes  of  fractures  through  the 
diploe  (Fig.  75).  These  fractures  are  almost  always  com})ound 
because  of  the  character  of  the  causative  violence,  the  skin  yielding 


Mechanism  of  fracture  of  the  internal  table 
by  bending  of  the  bone. 


FRACTURES  OF  THE  SKULL. 


Ul 


under  it  as  the  bone  does.     They  are  part  of  the  so-called  "  compound 
comminuted  depressed  fractures  of  the  skull." 

All  of  the  injuries  thus  far  described  belong  in  what  are  termed  the 
second  group  in  the  opening  paragraph  of  this  chapter,  those  in  which 


Fig.  73. 


Circumscribed  fracture  wltli  inclusion  of  hair.    (Konig.) 

the  dominant  feature  is  the  fracture  and  in  which  injury  to  the  brain 
is  usually  absent  or  strictly  localized.  This  feature  is  of  so  great  prac- 
tical importance  that  I  wish  it  might  be  indicated  in  the  classifying 

Fig.  74. 


Circumscribed  depressed  fructure.     (Konig.) 


nomenclature,  to  the  exclusion,  or  at  least  the  great  subordination,  of 
"depression,"  which  has  long  hold  the  attention  of  the  surgeon,  to  the 
hopeless  confounding  of  radically  ditlerent  cases  and  the  u.scless  <»r 


146 


FRA  CTURES. 


harmful  generalization  of  therapeutic  measures  the  value  of  ■which  is 
strictly  limited.  I  have  long  sought  such  a  name  that  ■svould  be  dis- 
tinctive and  short;  possibly  "circumscribed  fracture  of  the  vault" 
would  serve  the  purpose,  although  it  is  far  from  meeting  all  the  indi- 
cations. 

The  vast  majority  of  fractures  of  this  class  involve  the  vault,  but 
they  occasionally  occur  at  the  base,  the  vulnerant  body  reaching  it 
through  the  mouth  or  orbit,  and  in  a  very  few  cases  even  the  condyle 
of  the  lower  jaw  has  been  driven  through  the  roof  of  its  socket,  or 
the  ethmoid  driven  in  by  a  blow  on  the  nose.  The  prognosis  is  worse 
in  these  basal  cases  because  important  parts  of  the  brain  are  usually 
injured,  efficient  treatment  is  impracticable,  and  infection  is  more 
likelv  to  occur. 


Fig.  75. 


Fig.  76. 


Circumscribed  depressed  fracture,  inner 
side ;  healed.     (Ko>"ig.; 


Gunshot  contusion  of  cranium,  •^itb  fracture   of 
internal  table,  interior  view.  (A.  M.  M.,  spec.  2313.) 


The  other  group  of  fractures,  those  produced  by  a  force  acting 
broadlv  upon  the  cranium  to  modify  its  shape  as  a  whole,  include 
almost  all  fractures  of  the  base,  and  all  so-called  "  indirect  fractures  " 
and  "  fractures  by  contrecoup  "  which  have  had  so  large  a  part  in  the 
discussion  of  this  subject.  In  these,  I  repeat,  the  important  lesion  is 
that  produced  in  the  brain ;  the  fracture  is  an  incident,  it  usually  has 
no  influence  upon  the  progress  of  the  case  and  gives  rise  to  no  thera- 
peutic indications.  Similar  brain  lesions  can  be  produced  without 
fracture,  and  these  cases  belong  among  injuries  of  the  brain  rather 
than  among  fractures.  This  makes  a  detailed  account  of  the  manv 
forms,  their  relative  frequency,  and   their   more   or  less   hypothetical 


fhagtures  of  the  skxjll.  147 

relations  to  different  forms  of  violence  unnecessary  in  a  work  of  the 
scope  of  this  one. 

The  mode  of  production  of  these  fractures  has  been  the  subject  of 
close  observation,  experiment,  and  study  by  many,  among  whom  I 
shall  mention  only  Aran,  Felizet,  Mcssemer,  and  Yon  AVahl.  Another, 
Duret,^  deserves  to  be  remembered,  perhaps  above  all  others,  for  his 
remarkable  investigations  and  his  theory  of  mechanism  by  which  the 
changes  of  shape  of  the  cranium  produce  the  often  distant  lesions  of 
the  brain  and  meninges,  a  theory  which,  even  if  carried  in  its  details 
somewhat  further  than  it  can  readily  be  followed,  and  possibly  even 
incorrect,  has  yet  been  most  valuable  in  fixing  the  attention  upon  the 
intracranial  lesions  and  clearing  a^ay  a  large  amount  of  nebulous 
theories  concerning  distant  effects  and  their  hypothetical  causes. 

The  theory  of  these  fractures  as  now  apprehended  is  based  in  part 
upon  the  shortening  of  the  diameter  in  the  direction  of  the  violence 
and  the  consequent  lengthening  of  those  at  right  angles  to  it,  and  in 
part  upon  the  overbending  of  the  bone  under  a  like  strain.  In  a 
globular  body  of  uniform  elasticity  the  shortening  of  one  diameter 
under  pressure  is  necessarily  accompanied  by  the  enlargement  of  the 
mass  in  the  line  of  the  equator  and  in  the  corresponding  separation 
of  the  meridians.  If  the  limit  of  cohesion  is  passed,  separation  (frac- 
ture) necessarily  takes  place  between  two  or  more  meridians,  and  the 
line  of  fracture  runs  approximately  from  pole  to  pole — that  is,  from 
the  point  struck  to  one  diametrically  opposite — along  a  meridian.  To 
these  Messemer  gave  the  name  of  "  bursting  fracture."  Thus,  in  the 
skull,  a  blow  received  in  the  centre  of  the  frontal  bone  and  directed 
backward  would  shorten  the  antero-posterior  diameter  and  enlarge  the 
skull  in  the  central  transverse  plane  at  right  angles  to  the  line  of  force, 
and,  if  strong  enough,  produce  one  or  more  fissured  fractures  running 
from  before  backward  along  the  summit  or  side  of  the  cranium.  If 
the  blow  were  received  upon  the  side  the  lines  of  fracture  would  be 
transverse  through  the  vault  or  base  or  both. 

Under  other  circumstances  not  fully  understood,  but  probably  de- 
pendent upon  lack  of  uniformity  in  or  differing  degrees  of  elasticity,  the 
yielding  along  the  line  of  impact  is  not  so  fully  or  so  promptly  met  by 
expansion  in  the  other  plane,  and  the  bone  breaks  at  the  point  of  maxi- 
mum curvature  at  the  periphery  of  the  depressed  area  and  along  what 
may  be  termed  a  parallel  of  latitude,  at  right  angles  to  the  line  of  force, 
producing  what  Von  Wahl  names  a  "bending  fracture."  Thus,  a  force 
acting  from  before  backward  upon  the  centre  of  the  frontal  bone  would 
produce  this  form  of  fracture  along  a  line  crossing  the  cranium  from 
side  to  side. 

The  lines  of  fracture  produced  in  these  two  ways  are  modified  by 
lack  of  uniformity  in  the  shape  and  structure  of  the  cranium  and  by 
the  degree  of  the  fracturing  force;  the  majority  of  those  involving  the 
base  and  limited  to  a  single  zone  occupy  the  middle  fossa,  and  in  those 
not  limited  to  a  single  zone  the  violence  appears  to  have  been  greater, 
and  the  portion  of  the  vault  which  has  received  the  blow  shows  ex- 

'  Buret:    Etudes  Expeiimeutales  et  Cliniques  sur  les  Traumatismes  Cerebraux,  Paris, 

1878. 


148  FRACTURES. 

tensive  splintering  (Von  Bergmann).  The  direction  of  fissures  lim- 
ited to  the  middle  fossa  is  in  the  great  majority  of  cases  transverse, 
following  one  of  two  paths,  either  in  the  anterior  part  of  the  petrous 
portion  of  the  temporal  bone,  parallel  to  its  long  axis  and  opening  into 
the  middle  ear,  or  further  forward  in  the  great  wing  of  the  sphenoid. 
The  cause  is  a  blow  upon  the  vertex  or  the  side  of  the  skull,  and  the 
fracture  ends  in  the  foramen  lacerum  anterius  or  in  the  sphenoidal 
fissure.  If  the  force  is  greater  the  fracture  may  extend  across  the 
sella  turcica  into  the  opposite  middle  fossa,  or  obliquely  through  the 
sphenoid  into  the  opposite  anterior  fossa,  or  into  the  anterior  fossa  of 
the  same  side.  Fractures  of  the  posterior  fossa,  caused  by  a  blow  on 
the  occiput,  are  rarely  limited  to  it,  but  cross  the  petrous  portion  to 
the  middle  fossa,  but  never  cross  the  occipital  ridge ;  and  those  of  the 
anterior  fossa  usually  pass  through  the  upper  margin  of  the  orbit  and 
run  back  to  the  optic  or  sphenoidal  foramen,  extending  sometimes  across 
the  middle  into  the  posterior  fossa,  sometimes  also  across  the  cribriform 
plate  to  the  other  orbit  (Konig).  In  crushing  fracture  of  the  bones  of 
the  face  longitudinal  fracture  of  the  base  along  the  body  of  the  sphe- 
noid appears  to  be  frequent. 

That  most  of  the  fractures  produced  in  this  manner  occupy  the  base 
with  but  little  or  no  extension  to  the  vault  is  to  be  explained  by  the 
less  resistance  of  the  base  due  to  its  relative  thinness  and  its  irregu- 
larity of  shape  and  also,  possibly,  in  part  to  the  impinging  force  or  the 
resistance  of  the  body  exerted  upon  the  base  by  the  spinal  column 
through  the  occipital  condyles.  AY  hen  the  vault  is  more  extensively 
involved  the  line  of  fracture  may  cross  it  completely  in  any  direction 
either  as  a  long  fissure  with  little  change  of  place  or  witb  a  separation 
so  free  that  tiie  two  halves  of  the  skull  can  be  freely  moved  upon  each 
other.  The  internal  table  shows  no  splintering.  The  short  isolated 
.  fissures  distant  from  the  point  struck,  which  are  seen  not  infrequently 
in  the  base  and  occasionally,  but  very  rarely,  in  the  vault,  are  produced 
in  a  variety  of  ways  and  will  be  considered  in  the  following  paragraph 
among  the  exceptional  forms.  Most  of  the  extensive  fissures  of  the 
vault'belong  in  what  was  spoken  of  in  the  opening  paragraph  of  this 
chapter  as  the  group  of  fractures  intermediate  between  the  two  main 
groups,  those  in  which  the  causative  violence  is  great  and  produces 
extensive  crushing  fracture  at  the  point  struck,  with  radiating  fissures 
and  generalized  lesion  of  the  brain.  They  are  sometimes,  but  not 
always,  compound. 

Exceptional  forms  of  fracture,  the  mode  of  production  of  some  of  which 
is  very  obscure,  are  found  at  many  points.  The  small  isolated  fissures 
at  a  distance  from,  or  even  directly  opposite,  the  point  struck,  to  which 
the  name  "fracture  by  contrecoup"  was  given,  belong  almost  all 
among  the  "  bursting "  or  "  bending "  fractures,  those  of  the  base 
(when  the  blow  has  been  received  upon  the  vertex)  being  due  to  the 
resistance  of  the  spinal  column  acting  through  the  occipital  condyles. 
The  cases  in  which  the  fracture  is  directly  opposite  the  point  struck 
are  so  few  and  so  doubtful  that  their  existence  has  been  denied,  yet 
Perrin  produced  experimentally  a  fracture  of  the  frontal  bone  by 
throwing  a  skull  upon  its  occiput,  and  therefore  the  possibility  must 


FRACTURES   OF  THE  SKULL.  149 

be  admitted.  Inclusion  in  this  group  of  fractures  at  such  a  point  pro- 
duced by  a  second  blow  directly  upon  it,  as  when  a  fracture  of  the 
occiput  is  caused  by  a  fall  upon  the  back  of  the  head  following  a  blow 
upon  the  forehead,  is,  of  course,  unjustifiable.  A  special  group  of 
nine  cases  collected  by  Von  Bergmann  ^  in  which  the  orbital  plate  was 
broken  is  of  great  interest.  In  four  cases  the  primary  violence  was 
by  a  glancing  bullet,  in  the  others  a  bullet  penetrating  the  temporal 
(3),  the  occipital  (1),  and  the  parietal  (1).  In  some  only  one  orbital 
plate  was  broken,  in  others  both  ;  the  fracture  was  either  a  straight 
fissure  or  circular;  in  President  Lincoln's  case^  (perforation  of  the 
occipital  by  a  bullet)  both  plates  were  broken  and  the  fragments 
''pushed  up  toward  the  brain;"  in  two  the  fragments  were  depressed 
a  few  millimetres  into  the  orbit.  In  an  allied  case  a  perfoi'ating  bullet 
wound  of  the  right  parietal  was  accompanied  by  a  fissure  extending 
from  the  sella  turcica  through  the  great  wing  of  the  sphenoid.  The 
explanation  offered  by  Longmore"^  and  Von  Bergmann  is  by  moment- 
ary excessive  intracranial  pressure  produced  by  the  penetration  of  the 
ball  or  the  bending  inward  of  the  vault. 

Fracture  of  the  posterior  clinoid  processes  is  occasionally  observed, 
evidently  produced  by  traction  upon  them  by  the  attached  tentorium 
during  elongation  of  the  antero-posterior  diameter  of  the  skull. 

The  so-called  "ring  fractures"  about  the  foramen  magnum  caused 
by  a  fall  upon  the  feet  or  buttocks  are  due  to  the  impact  of  the  skull, 
through  the  occipital  condyles,  upon  the  upper  end  of  the  spinal  col- 
umn, just  as,  to  use  Felizet's  comparison,  the  head  of  a  hammer  is 
driven  firmly  down  upon  its  handle  by  striking  the  other  end  of  the 
latter  against  the  ground. 

Exceptional  isolated  fractures  of  the  base  by  direct  violence  have 
been  referred  to,  such  as  those  produced  by  the  passage  of  a  bullet,  a 
stick,  or  a  knife  through  the  orbit  or  the  mouth,  fracture  of  the 
ethmoid  by  a  blow  upon  the  nose,  or  fracture  of  the  temporal  by  the 
pressure  of  the  condyle  of  the  inferior  maxilla  in  a  blow  upon  the 
chin.  Fracture  of  the  anterior  wall  of  the  auditory  canal  by  the  same 
cause  deserves  mention  because  of  the  bleeding  from  the  ear  which  it 
occasions  and  which  may  be  mistaken  for  that  following  fracture  of  the 
petrous  portion  of  the  temporal  bone.  These  fractures  owe  their  impor- 
tance to  the  associated  injuries  of  the  contents  of  the  cranium,  espe- 
cially of  the  carotid  artery  and  cavernous  sinus  in  wounds  through  the 
orbit,  and  to  the  possibility  of  the  spread  of  infection  from  the  outside 
to  the  interior. 

Fractures  of  the  Internal  Table.  These  are  apparently  extremely  rare. 
In  the  Medical  and  Surgical  History  of  the  War  of  the  RebeUion  twenty 
cases  observed  during  the  war  are  recorded  and  brief  notes  are  given 
of  twenty-nine  cases  reported  during  the  preceding  two  hundred  years. 
Von  Bergmann  describes  three  additional  specimens.  In  the  great 
majority  of  the  reported  cases  the  cause  was  a  blow  by  a  glancing 
bullet  which  exposed  the  bone  but  left  the  outer  table  uninjured  or 
only  grooved  or  contused  ;  among  the  other  causes  are  blows  witii  small 

'  Von  Bergmann  :  Dontsche  Chirurgie,  Lief.  .30,  j).  '21 1. 

2  Surg.  Hist.  War  of  the  Rebellion,  vol.  i.  p.  30.^).         *  Lancet,  1865,  vol.  ii.  p.  649. 


150  FRACTURES. 

round  objects,  such  as  a  hammer,  a  cricket-ball,  a  beer  glass ;  in  only- 
one  case  was  the  cause  a  fall  upon  the  head.  The  alleged  greater 
brittleness  of  the  internal  table  appears  to  be  entirely  foreign  to  this 
limitation  of  the  effect  of  the  blow,  the  cause  of  which  is  the  over- 
bending  of  the  table  as  described  above. 

The  fracture  may  be  a  simple  fissure,  one  side  of  which  is  slightly 
depressed,  or  circumscribing  and  detaching  a  scale  of  bone,  or,  more 
commonly,  a  comminuted  one  with  a  marked  central  depression  (Fig. 
73).  The  dura  may  be  torn  or  the  small  fragment  may  be  forced 
entirely  through  it.  In  one  case  the  middle  meningeal  artery  was  torn. 
In  some  of  the  cases  close  examination  after  death  has  shown  a  slight 
fissure  of  the  outer  table  and  diploe.  As  almost  all  the  reported  cases 
have  ended  fatally,  usually  in  consequence  of  suppuration  of  the  super- 
ficial wound  and  extension  of  the  infection  to  the  interior  of  the  cra- 
nium, it  is  possible  that  many  other  cases  not  thus  complicated  have 
ended  in  recovery  and  passed  unrecognized  ;  the  inference  then  would 
be  that  the  danger  to  life  lay  not  in  the  fracture  or  in  the  displacement 
of  a  fragment  but  in  the  coexisting  wound  and  the  spread  of  infection 
from  it. 

The  coincident  injuries  of  the  contents  of  the  cranium  are  rupture  of 
the  dura  and  pia,  laceration  and  contusion  of  the  brain,  rupture  of 
arteries,  venous  sinuses,  and  cranial  nerves,  and  multiple  extravasations 
of  blood  from  the  smaller  vessels  on  the  surface  of  the  brain  and  ven- 
tricles and  less  frequently  in  its  substance. 

The  dura  is  rarely  torn  except  when  the  fragments  are  notal^ly  driven 
inward,  and  then  only  to  a  moderate  extent.  Direct  contusion  and 
laceration  of  the  brain,  recognizable  macroscopically,  is  found  only 
under  the  same  circumstances,  but  there  is  reason  to  believe  that  even 
in  the  slighter  cases  it  receives  a  contusion  which  makes  it  peculiarly 
liable  to  be  secondarily  affected  by  infection  proceeding  from  suppura- 
tion of  the  adjoining  scalp ;  that  is,  central  abscesses  and  cysts  which 
are  probably  not  the  remains  of  hemorrhages  are  occasionally  observed, 
the  former  after  suppuration  of  the  scalp,  the  latter  after  even  simple 
fracture. 

The  hemorrhages  from  the  vessels  of  the  pia  which  are  constant  in 
the  "bursting"  and  "bending"  fractures  are  attributed  by  Duret  to 
rupture  of  the  smaller  vessels  by  the  sudden  forced  shifting  of  the 
cerebro-spinal  liquid  under  the  influence  of  the  blow  and  the  change 
in  the  shape  of  the  skull  thereby  produced,  by  which  certain  portions 
of  the  space  in  which  it  is  contained  are  sharply  distended  and  the 
connected  vessels  torn.  The  effects  are  seen  not  only  on  the  surface 
of  the  brain  or  in  the  subarachnoid  space  but  also  within  the  cortex 
and  in  the  ventricles,  especially  the  fourth,  and  it  is  to  these  that  many 
of  the  cerebral  symptoms  are  to  be  attributed.  This  also  is  the  expla- 
nation of  the  presence  of  the  hemorrhages  found  at  points  distant  from 
the  one  struck. 

Rupture  of  the  middle  meningeal  artery  is  followed  by  increasing 
extravasation  of  blood,  usually  between  the  dura  and  the  skull,  with 
quite  characteristic  symptoms  and  the  possibility  of  relief  by  operation. 

Rupture  of  the  cavernous  sinus,  and  more  rarely  of  tlie  carotid  artery 


FRACTURES   OF  THE  SKULL.  151 

where  it  lies  within  it,  is  seen  in  some  fractures  of  the  base  and  espe- 
cially in  those  due  to  the  entrance  of  the  vulnerant  body  through  the 
orbit.  Occasionally  an  arterio-venous  aneurysm  results.  The  other 
sinuses  may  also  be  torn  when  the  line  of  fracture  crosses  them,  but 
the  complication  seems  rarely  to  be  important. 

Laceration  of  a  cranial  nerve  is  rare ;  the  facial  most  frequently. 
But  interference  with  function  by  hemorrhage  into  the  sheath  of  a 
nerve  is  more  common. 


Pathological  and  Reparative  Processes  following-  Fracture. 

These  diifer  radically  according  as  infection  is  present  or  absent,  and 
while  this  difference  does  not  exactly  coincide  with  that  of  simple  and 
compound  fractures,  yet  the  existence  of  an  open  wound  in  communi- 
cation with  or  even  near  the  fracture  creates  dangers  which  are  almost 
wholly  absent  from  simple  fractures. 

Repair  of  the  fracture  is  eifected  largely  by  the  diploe,  and  although 
the  pericranium  and  dura  can  each  produce  bone  they  usually  do  so  to 
only  a  slight  extent,  and  consequently  an  overgrown  callus  is  rare. 
Moreover,  the  osteogenetic  action  is  rarely  sufficient  to  close  even  a 
small  gap  in  the  bone,  so  that  gaps  created  by  the  removal  of  frag- 
ments or  trephining  are  habitually  closed  only  by  fibrous  tissue  with 
at  the  most  a  small  margin  of  new  bone  along  the  edge  of  the  opening. 
And  yet  in  a  case  in  which  I  removed  fully  two  square  inches  from 
the  frontal  bone,  broken  by  a  blow  with  a  hammer,  I  found  twenty- 
five  years  afterward  firm,  apparently  bony,  resistance  over  the  entire 
area.  Depressed  fragments  heal  in  the  position  in  which  they  are  left, 
and  large  broad  depressions  in  infants  will  often  be  diminished  by 
intracranial  pressure. 

Persistent  depression  in  the  motor  area  may  maintain  a  correspond- 
ing paralysis  by  its  local  pressure  upon  the  cortex,  but  the  weight  of 
surgical  opinion  at  the  present  time  is  opposed  to  the  belief  that  it  has 
any  marked  influence  in  producing  irritation  or  other  functional  dis- 
turbances, such  as  epilepsy.^  It  has  been  abundantly  shown  clinically 
and  by  experiment  that  the  brain  readily  accommodates  itself  to  a 
marked  diminution  of  the  cranial  capacity,  and  that  even  a  sudden 
diminution  must  amount  to  about  two  cubic  inches  in  the  adult  skull 
before  it  can  of  itself  ])roduce  permanent  symptoms  of  general  com- 
pression. In  very  few  fractures  is  the  depression  as  great  as  that,  and 
the  symptoms  which  accompany  it  rarely  differ  from  those  of  other 
fractures  with  little  or  no  depression.  That  cerebral  symptoms  have 
been  promptly  relieved  by  the  removal  of  a  depressed  portion  of  bone 
does  not  prove  that  the  de[)ression  was  their  cause,  for  similar  relief 
has  often  been  given  by  the  removal  of  portions  that  were  not  depressed 
or  in  any  way  altered,  and  even  by  operations  on  distant  parts  of  the 
body.  The  clinical  grounds  for  the  belief  that  the  scar  following 
removal  of  a  portion  of  the  skull  is  able  to  cause  functional  disorders 
are  as  good  as  those  that  a  persistent  depression  can  do  so.     It  seems 

1  See  Voii  Bergman n,  Konij;,  Hutchinson,  in  London  Hospital  Reports,  vol.  vi.  ;  Eciic- 
verria,  Arch.  Gen,  de  Med.,  lH7b. 


152  FRACTURES. 

probable  that  if  the  dura  is  torn,  and  intraraeningeal  adhesions  thereby 
produced,  the  chances  of  chronic  irritation  and  functional  derangement 
are  greater  than  if  such  adhesions  do  not  exist. 

Contusion  of  the  brain  and  laceration  of  its  vessels  and  of  those  of 
the  pia,  in  uncomplicated  cases  in  which  the  patient  survives  the  pri- 
mary injury,  heal  kindly,  and  the  cases  in  which  they  give  rise  to  a 
meningitis  of  any  extent  or  importance  are  very  exceptional.  The 
extravasated  blood  is  absorbed,  or  occasionally  remains  as  a  cyst. 
Occasionally,  but  very  rarely,  suppuration  takes  place  beneath  a  simple 
fracture,  just  as  it  does  in  closed  injuries  in  other  parts  of  the  body. 

Generalized  contusion  of  the  brain,  as  seen  in  the  "bursting"  and 
"  bending  "  fractures  and  in  those  of  the  intermediary  group,  is  gen- 
erally fatal,  but  not  through  meningitis.  The  lesions  are  more  exten- 
sive than  those  of  most  apoplexies  and  apparently  they  kill  in  like 
manner.  Even  in  fractures  of  the  base  with  rupture  into  the  middle 
ear  the  cases  in  which  an  intracranial  infection  has  originated  through 
this  communication  with  the  exterior  are,  in  my  experience,  very  rare. 
It  is  the  cerebral  lesion  that  kills,  not  the  fracture  or  any  secondary 
result  of  the  fracture. 

In  compound  fractures  when  infection  is  avoided  repair  goes  on  in 
the  same  manner ;  but  if  the  wound  suppurates  the  infection  may  spread 
not  only  to  the  bone  but  also,  as  in  cases  of  phlegmon  without  fracture, 
to  the  interior  of  the  cranium  by  lymph  channels,  connective  tissue, 
and  thrombi  in  the  veins,  and  thus  give  rise  to  suppurative  meningitis 
and  pypemia.  In  short,  the  progress  of  a  case  is  determined  mainly 
by  the  character  and  extent  of  the  intracranial  lesions  and  the  pres- 
ence or  absence  of  infection,  and  the  fracture,  as  such,  usually  has  but 
little  influence  upon  it. 

Symptoms,  Diagnosis,  and  Treatment. 

The  distinction  which  has  been  made  between  those  cases  in  which 
the  fracture  is  an  important,  perhaps  the  principal,  lesion  and  those  in 
which  it  is  only  a  comparatively  unimportant  accompaniment  of  grave 
lesions  of  the  brain  and  its  annexa  must  here  be  kept  constantly  in 
mind.  Fortunately,  in  the  former,  in  which  the  recognition  of  the 
fracture  is  important  because  of  the  therapeutic  indications  which  arise 
from  it,  the  diagnosis  is  usually  easy  ;  and  in  the  latter,  in  which  the 
fracture  seldom  demands  or  can  receive  any  direct  treatment  or  affects 
in  any  way  the  'prognosis,  and  in  which  the  practical  interest  is  limited 
to  the  intracranial  injuries,  the  fact  that  the  existence  of  a  fracture  can 
only  be  inferred,  and  not  be  demonstrated,  does  not  leave  us  less  able 
to  do  all  that  can  be  done  for  the  patient.  Instead,  therefore,  of  fol- 
lowing the  usual  division  of  the  subject — fractures  of  the  vault  and 
fractures  of  the  base — I  shall  use  that  of  circumscrihed  fractures  of  the 
vault  and  fissurefl  fractures  vith  (jeneralized  brain  injuri/,  with  separate 
consideration  of  the  rarer  forms  \\hich  lie  outside  of  this  grouping. 
Furthermore,  as  diagnostic  and  therapeutic  measures  in  many  cases 
run  closelv  together  or  even  coincide,  I  shall  at  the  same  time  consider 
the  treatment. 


FRACTURES  OF  THE  SKULL.  153 

Circumscribed  Fractures  of  the  Vault. 

As  these  fractures  are  produced  by  a  blow  from  a  relatively  small 
body  or  from  oue  having  an  edge  or  corner,  the  fracture  is  often  com- 
pound and  the  diagnosis  is  made  by  direct  inspection  and  palpation  of 
the  bone.  In  most  cases  there  is  no  difficulty ;  the  fragments  can  be 
seen  and  felt  at  the  bottom  of  the  wound,  and  it  remains  only  to  deter- 
mine the  extent  of  the  fracture  and  apply  the  appropriate  treatment. 
In  the  doubtful  cases  the  bone  has  to  be  carefully  examined  in  search 
of  a  fissure,  or  its  condition  and  the  character  of  the  violence  con- 
sidered as  bearing  upon  the  probability  of  a  fracture  of  the  internal 
table. 

In  respect  of  a  fissure  the  edge  of  the  torn  periosteum  can  easily  be 
mistaken  for  one  by  touch,  or  a  cranial  suture  by  the  eye.  The  error 
in  the  first  case  is  so  easily  made,  even  when  one  is  on  his  guard  against 
it,  that  the  finger  should  not  be  trusted  ;  in  the  second  the  fissure  can 
generally  be  recognized  by  its  bleeding,  when  fresh  or  when  rubbed. 
The  importance  of  its  recognition  comes  from  its  possible  indication  of 
more  extensive  fracture  beneath  and  from  the  frequent  advisability  of 
enlarging  it  for  thorough  disinfection. 

When  the  bone  is  distinctly  broken  and  depressed,  even  when  the 
area  is  small,  the  depressed  portion  should  be  raised.  If  it  proves  to 
be  only  a  fracture  and  depression  of  the  outer  table  the  operation  needs 
to  be  carried  no  further  ;  the  wound  is  washed  and  closed.  If  the 
entire  thickness  of  the  bone  is  broken  the  deeper  as  well  as  the  super- 
ficial fragments  must  be  removed.  It  is  rarely  necessary  to  use  a 
trephine  for  this  purpose,  for  the  corner  of  a  chisel  or  elevator  can  be 
engaged  under  the  edge  of  a  fragment  and  used  to  raise  it,  and  after  one 
piece  has  been  removed  the  removal  of  the  deeper  ones  is  easy,  for  they 
can  be  grasped  with  forceps  and  withdrawn  by  careful  traction;  the 
amount  of  internal  table  removed  is  usually  greater  than  that  of  the 
outer  table.  If  the  dura  is  torn,  and  there  is  no  bleeding  from  the  pia,  the 
opening  in  the  dura  should  be  closed  with  catgut  sutures;  if  there  is 
free  bleeding  from  the  pia  the  wound  should  be  packed  with  gauze  for 
a  few  hours,  after  which  the  opening  in  the  dura  may  be  closed.  The 
overlying  soft  parts,  including  the  pericranium  as  far  as  possible,  should 
be  closed  with  sutures,  a  small  gauze  drain  being  inserted  and  main- 
tained for  a  day  or  two.  The  scalp  should  be  shaved  for  some  distance 
about  the  wound  and  thoroughly  disinfected  before  anything  is  done 
to  the  bone. 

When  the  gap  left  by  the  removal  of  bone  is  large  and  the  wound 
is  clean  a  thin  sheet  of  aluminum,  celluloid,  rubber  tissue,  or  foil  cut 
to  fit  it  may  be  inserted  in  it.  The  softer  materials  seem  to  answer  as 
well  as  the  firmer  ones  by  leading  to  the  formation  of  a  thick  and 
tough  cicatrix.  Gold  foil  or  rubber  tissue  has  sometimes  been  placed 
beneath  the  torn  dura  to  prevent  meningeal  adhesions,  but  either  is 
liable  to  induce  exaggerated  cicatricial  formation. 

Brewitt^  published  a  series  of  remarkable  results  obtained  by 
replacing  the  fragments  and  closing  the  wound  over  them.    Of   .'^S 

1  Brewitt:  Arfh.  fiir  klia.  Chir.,   1906,  vol.  Ixxix.,  p.  47. 

u 


154  FRACTURES. 

cases  2  died ;  in  all  the  others  primary  healing  took  place,  and  in 
28  of  them  the  fragments  united  solidly  on  a  level  with  the  adjoining 
bone;  in  the  others  there  was  some  depression  of  the  surface.  He 
also  claims,  with  statistics  in  support,  that  patients  thus  treated  are 
also  more  free  from  late  ill  effects. 

Morestin,^  who  has  done  brilliant  plastic  work  on  the  nose  and 
jaw  with  grafts  of  costal  cartilage,  has  used  them  also  with  uniform 
success  in  a  large  number  of  cases  to  close  the  gap  left  by  gunshot 
wounds  and  trephining.  He  awaits  cicatrization,  then  excises  the 
cicatrix  and  fills  the  entire  gap  in  the  skull  with  strips  of  cartilage, 
taking  care  to  fill  the  gap  completely.  He  rarely  uses  the  entire  thick- 
ness of  the  cartilage,  but  splits  it  or  takes  thick  shavings  from  it. 

In  small  perforations,  as  by  a  nail  or  even  by  the  end  of  a  small 
stick  (the  handle  of  a  paint-brush  in  one  of  my  own  cases),  the  open- 
ing must  be  enlarged  by  the  chisel  or  trephine  for  the  better  cleaning 
of  the  deeper  parts  of  the  wound  ;  and  in  pistol-shot  fractures  this  is 
also  necessary,  but  only  for  the  same  purpose  and  for  the  removal  of 
the  ball,  if  it  is  within  easy  reach,  and  of  small  fragments.  Bullets 
can  heal  in,  and  without  giving  rise  to  late  consequences  ;  and  I  think 
the  risks  of  attempts  to  remove  a  bullet  are  greater  than  those  of  leav- 
ing it  in  place  if  the  orifice  of  entry  is  the  only  communication  with 
the  exterior  and  can  be  thoroughly  cleaned.  If  the  bullet  in  its  pas- 
sage has  opened  the  ethmoid  cells  or  the  frontal  sinus  infection  from 
that  side  is  probable  and  the  bullet  should  be  removed  if  possible,  but 
whether  it  is  removable  or  not  the  prognosis  is  thoroughly  bad. 

In  any  of  these  cases  there  may  be  free  hemorrhage  from  within  the 
cranium  and  escape  of  brain  tissue,  or,  very  rarely,  a  flow  of  cerebro- 
spinal liquid  coming  from  the  subarachnoid  space  or  even  from  the 
lateral  ventricle.  Bleeding  from  a  wounded  sinus  can  be  arrested  by 
lateral  ligature  or  suture  or  by  packing. 

Circumscribed  depression  without  wound  of  the  soft  parts  may  be  recog- 
nized by  the  finger,  which  when  carried  firmly  along  from  the  adjoining 
bone  appreciates  the  change  in  level,  but  a  very  similar  sensation  is 
given  by  the  swollen  circular  margin  of  a  deep  contusion  ;  that  is,  the 
finger  passes  over  a  firm  rim  to  a  soft  central  area  which  suggests 
depression.  Error  can  be  avoided  by  making  firm  pressure  on  the 
hard  margin  and  then  passing  slowly  toward  the  centre  ;  the  mai'gin 
yields  under  the  pressure  and  the  finger  recognizes  the  level  resistance 
of  the  bone  throughout. 

In  these  cases,  as  in  the  preceding,  general  symptoms — cerebral  shock 
or  contusion — may  be  slight,  transient,  or  absent ;  the  stunning,  the 
partial  or  complete  unconsciousness  passes  and  is  perhaps  followed  by 
nausea  and  headache  ;  if  they  are  more  than  this  they  indicate  gener- 
alized lesions  that  bring  the  case  into  the  intermediate  group,  to  be 
subsequently  considered.  If  the  depression  is  immediately  over  a  por- 
tion of  the  motor  area  or  a  special  centre  there  may  be  a  corresponding 
paralysis  or  abolition  of  function.  Very  rarely  a  fluctuating  tumor 
may  form  under  the  skin  which  on  puncture  proves  to  contain  cerebro- 

1  Morestin:  Bull  de  la  Soc.  de  Chir.,  1916,  p.  973. 


FRACTURES  OF   THE  SKULL.  155 

spinal  liquid  that  has  escaped  through  the  torn  dura.    This  has  been 
observed  only  in  young  children. 

In  the  treatment  of  these  simple  circumscribed  fractures  with  depres- 
sion there  are  two  things  to  be  considered :  the  effect  upon  the  brain  and 
meninges  if  the  depression  persists,  and  the  risks  involved  in  relieving 
it.  The  reasons  have  been  given  above  for  the  belief  that  persistent 
depression  is  not  often  responsible  for  the  late  functional  disturbances 
that  have  been  attributed  to  it,  and  that  consequently  it  does  not,  in 
the  absence  of  special  indications,  imperatively  require  relief.  But, 
on  the  other  hand,  although  it  is  properly  urged  that  the  unbroken 
skin  is  a  safer  protection  against  infection  than  the  strictest  asepsis 
(Konig),  yet  the  danger  incurred  in  making  an  opening  in  the  vault  of 
the  cranium,  especially  if  the  dura  is  not  wounded,  is  so  slight  that  I 
cannot  criticise  those  who  act  upon  the  conviction  that  it  is  less  than 
those  of  persistent  displacement  even  when  the  disadvantages  of  the 
resultant  gap  are  taken  into  account.  This  applies  only  to  small  areas 
of  depression  and  the  removal  of  only  a  small  portion  of  bone.  The 
special  indications  referred  to,  which  call  for  operation,  are  found  in 
tiic  evidences  of  localized  pressure  or  of  hemorrhage  from  a  branch  of 
tlie  middle  meningeal  artery.  (See  below.)  The  value  of  a  localized 
symptom  (monoplegia,  etc.)  is  much  greater  in  a  fresh  injury  than 
when  it  occurs  after  the  lapse  of  a  few  days,  for  in  the  latter  case  it 
may  be  due  to  the  spread  of  inflammation  from  a  primary  focus  at 
some  little  distance  from  the  centre  which  corresponds  to  the  paralysis. 

Fissured  Fractures  with  Generalized  Brain  Injury. 

These,  let  me  repeat,  are  the  "  bending  "  and  "  bursting  "  fractures 
produced  by  violence  acting  broadly  upon  the  skull,  changing  its  shape 
temporarily  beyond  the  limits  of  its  elasticity,  and  causing  contusion 
of  the  brain  with  larger  or  smaller  hemorrhages  especially  upon  its 
surface.  In  the  great  majority  the  fracture  occupies  or  extends  to  the 
base  of  the  skull,  and  the  injury  is  hence  generally  spoken  of  as  fracture 
of  the  base.  The  principal  injury  is  the  lesion  of  the  brain,  and  the 
associated  fracture  is  mainly  of  importance  as  indicating  that  the  injury 
to  the  brain  is  probably  extensive  and  grave.  The  opinion  long  held 
that  fractures  of  the  base  were  necessarily  fatal  has  been  shown  to  be 
exaggerated,^  but  yet  the  percentage  of  mortality  is  high,  and  similarly 
produced  fractures  of  the  vault  have  a  like  gravity.  In  ten  years — 
bS95-1904 — 319  cases  of  fracture  of  the  base  were  treated  at  the 
Hudson  Street  Hospital,  with  206  deaths.  The  chief  symptom  of 
the  brain  injury  is  unconsciousness,  more  or  less  complete,  with  the 
history  of  a  blow,  irregularity  of  the  pupils,  and  a  moderate  rise 
of  temperature.  There  may  also  be  the  signs  of  compression  :  slow- 
ing of  the  pulse,  increase  of  bloodpressure,  and  choked  disc.  Tiie  high 
temperatures  which  have  been  spoken  of  as  constant,  105°  to  107°  F. 

1  Graf  (Deutsche  Zeitschrift  fur  Chir.,  vol.  Ixviii.,  p.  464)  sives  statistics  of  90  cases 
of  fracture  of  the  base  treated  at  the  Charite  in  BerUri  between  INiKi  and  1902,  nichid- 
iuK  the  condition  after  recovery  in  48  of  them.  There  were  34  deaths.  The  most  common 
late  result  was  diminution  of  the  hearing  in  27  of  39  cases  exanuned.  In  2  there  was 
persistent  facial  paralysis. 


156  FRACTURES. 

(Phelps),  I  have  seen  only  in  the  few  hours  before  death.  Paralytic 
s}Taptoms  and  s^Taptoms  connected  with  the  circulation  and  respiration 
depend  upon  the  portions  of  the  brain  and  medulla  involved  in  the  injury. 

The  differentiation  is  from  other  forms  of  coma,  especially  the  alcoholic, 
and  is  often  extremely  difficult  or  even  impossible,  as  when  alcoholism 
coincides  with  trauma.  The  points  of  difference  (with  many  exceptions) 
are  that  in  alcoholic  coma  the  temperature  is  not  raised,  the  unconscious- 
ness is  less  deep,  the  pupils  are  equal  and  responsive.  It  must  always 
be  remembered  that  the  two  conditions  may  coexist. 

During  the  past  year  I  have  withdrawn  by  lumbar  puncture  a  few 
drops  of  the  cerebrospinal  liquid  in  many  cases  of  unconsciousness  due 
to  various  causes,  in  the  hope  of  finding  that  the  presence  or  absence 
of  blood  in  it  would  aid  in  the  differential  diagnosis.  Blood  was  almost 
invariably  present  in  fracture  of  the  skull,  and  also  in  many  apoplexies. 
The  diagnostic  value  of  its  presence  is  considerably  diminished  by  the 
fact  that  it  is  caused  not  infrequently  by  the  puncture  itself,  presumably 
by  wounding  a  meningeal  vein. 

The  symptoms  belonging  to  the  fracture  itself  are  hemorrhages, 
ecchymoses,  occasionally  a  watery  discharge  from  the  ear  or  nose,  and 
deafness  of  the  ear  of  the  affected  side. 

Hemorrliage  from  the  ear,  nose,  or  mouth  is  frequent,  that  from  the 
ear  being  almost  pathognomonic  of  a  fracture  through  the  petrous  por- 
tion of  the  temporal  bone ;  it  is  usually  slight  but  may  be  profuse. 
Konig  refers  to  a  case  in  which  the  flow  from  the  middle  ear  through 
the  Eustachian  tube  into  the  mouth  was  so  abundant  that  he  felt  obliged 
to  do  tracheotomy  to  prevent  suffocation.  Bleeding  from  the  ear  which 
may  be  mistaken  for  that  of  a  fracture  of  the  base  may  be  due  to  rup- 
ture of  the  membrana  tyrapani  or  to  injury  of  the  external  auditory 
canal  by  a  blow  upon  the  chin  which  has  forced  the  condyle  of  the  jaw 
backward,  or  even  to  a  fissure  of  the  vault  extending  to  the  mastoid 
process. 

Ecchymosis  at  certain  points,  not  due  to  direct  contusion,  is  signifi- 
cant of  fracture.  A  frequent  one  is  that  beneath  the  ocular  conjunctiva, 
spreading  to  that  of  the  lids  and  then  to  the  skin  of  the  latter ;  it 
is  most  constant  and  marked  in  fractures  of  the  orbital  plate  and 
sphenoid.  A  slight  ecchymosis  behind  the  ear  is  often  found  after  a 
day  or  two. 

A  -watery  discharge  from  the  ear  after  fracture  of  the  base  is  not 
infrequent  and  is  sometimes  very  profuse  (in  one  case  63  ounces  in 
four  and  one-half  days).  Four  varieties  differing  in  the  amount  and 
character  of  the  discharge  have  been  observed:  (1)  The  flow  is  abun- 
dant and  prolonged,  the  liquid  contains  a  large  proportion  of  chloride  of 
sodium  and  but  little  albumin,  and  is  then  doubtless  the  cerebro-spinal 
liquid  of  the  subarachnoid  space  and  sinuses  escaping  through  frac- 
ture of  the  internal  auditory  canal  and  rupture  of  the  tympanum.  (2) 
The  flow  is  similar,  but  the  liquid  is  highly  albuminous  and  without  chlo- 
ride of  sodium  ;  autopsy  in  some  cases  has  shown  a  fracture  through  the 
middle  and  internal  ear  but  not  through  the  internal  auditory  canal ; 
the  liquid  is  probably  lymph  coming  from  the  large  arachnoid  lymph- 
space  which  normally  connnunicates  with  that  occupied  by  the  peri- 


PRACTURES  OF   THE  SKULL.  157 

lymph  of  the  labyrinth  or  liquid  Cotunnii.  (3)  The  flow  is  abundant 
and  albuminous,  becoming  scanty  and  purulent;  probably  an  inflam- 
matory discharge  from  the  surface  of  the  cavity  of  the  tympanum. 
(4)  The  flow  is  scanty,  appears  late,  is  albuminous  and  reddish,  and  is 
probably  the  serum  of  extravasated  blood. ^ 

Deafness  of  the  ear  of  the  affected  side  is  due  to  injury  of  the  middle 
or  internal  ear  or  of  the  acoustic  nerve  in  its  passage  through  the  bone., 

Paralysis  of  other  cranial  nerves  is  occasionally  observed,  the  result 
of  direct  injury  of  the  nerve  or  of  pressure  upon  it  by  extravasated 
blood  ;  the  facial  is  the  one  most  frequently  aifected,  then  the  abdu- 
cens.  Paralysis  of  the  limbs  is  caused  by  intracranial  hemorrhage. 
Slowino;  of  the  poise  and  irregularity  of  the  respiration  indicate  hem- 
orrhao:e  in  the  medulla. 

Fissured  fractures  of  the  vault  are  sometimes  recognizable  by  a  differ- 
ence in  the  level  of  the  two  sides  and  even  in  rare  cases  by  the  inde- 
pendent mobility  of  the  two  parts  of  the  cranium.  Auscultatory 
percussion  has  been  alleged  to  be  a  means  of  recognition  of  a  fissure, 
but  I  have  found  it  M^holly  untrustworthy.  The  general  symptoms  are 
the  same  as  when  the  fracture  occupies  the  base  and  are  dependent  upon 
similar  lesions  of  the  brain. 

Emphysema  of  the  scalp  is  a  rare  symptom  and  is  due  to  the  escape 
of  air  into  it  after  fracture  opening  the  mastoid,  frontal,  or  ethmoid 
sinuses. 

The  treatment  of  these  fractures  is  medicinal  and  expectant  :  absolute 
quiet,  light  diet,  laxatives,  and  cold  to  the  head  if  indicated  by  rest- 
lessness, headache,  or  other  symptoms  of  cerebral  irritation.  In  frac- 
tures of  the  base  with  bleeding  from  the  ear  a  light  plug  of  iodoform 
gauze  may  be  placed  in  the  external  meatus,  but  more  active  measures 
to  disinfect  this  region  seem  to  me  wholly  uncalled  for  in  view  of  the 
fact  that  a  route  for  infection  from  the  mouth  through  the  Eustachian 
tube  remains  and  cannot  be  protected. 

Gushing  2  has  reported  excellent  results  in  cases  of  bursting  fracture 
with  symptoms  of  compression  from  the  "  subtemporal  decompressive 
operation;"  13  recoveries  out  of  15  cases.  His  incision  runs  from 
a  point  about  midway  between  the  edge  of  the  orbit  and  the  top  of  the 
ear  upward  and  backward.  The  fibres  of  the  temporal  muscle  are 
drawn  widely  apart,  a  disc  four  centimeters  in  diameter  removed  from 
the  temporal  bone,  and  the  dura  opened.  Drainage  is  maintained  for 
two  days. 

I  do  not  think  it  should  be  adopted  as  a  routine  treatment.  Some 
cases  are  plainly  hopeless  from  the  beginning;  others — 35  per  cent,  in 
my  statistics — recover,  generally  without  having  shown  alarming  symp- 
toms at  any  time;  others,  in  an  intermediate  class,  those  which  without 
evidence  of  a  probably  fatal  injury  at  the  beginning,  do  not  improve 
but  instead  grow  worse,  may  be  proper  subjects  for  decompression. 

When  the  fracture  involves  the  vault  and  is  compound  the  wound 

1  For  interesting  details  of  these  symptoms  the  reader  is  referred  to  Hewett,  in  Holmes's 
System,  vol.  i;  Von  Bergmann,  in  Deutsche  Chirurgio,  Lief.  30,  and  Roswcll  Park. 

2  Gushing:  Annals  of  Surg.,  May,  1908,  p.  041. 


158  FRACTURES. 

should  be  thoroughly  cleansed,  and  to  this  end  it  is  proper  to  chisel 
away  the  sides  of  the  fissure,  but  I  do  not  think  it  judicious  to  enlarge 
the  wound  in  the  scalp  in  order  to  follow  up  the  fissure  and  treat  it 
thus  throughout  its  entire  length.  The  interference  is  solely  for  disin- 
fection, and  in  fresh  cases  we  may  be  confident  that  infection  has  not 
passed  much  beyond  the  limits  of  the  external  wound.  Depression  of 
one  side  of  a  fissure  of  the  vault  is  not  a  justification  for  making  an 
incision  through  the  unbroken  skin. 

The  same  principles  apply  to  the  treatment  of  the  intermediary 
group — extensive  comminuted  fractures  with  marked  general  cerebral 
symptoms.  The  important  lesion  is  that  of  the  brain,  and  it  is  not 
probable  that  good  can  be  got  by  removal  of  fragments  or  relief  of 
depression  that  will  compensate  for  the  risk  incurred  in  dividing  the 
unbroken  scalp.  Possibly  the  relief  of  tension  by  draining  away  the 
exudate  through  an  incision  may  be  an  important  advantage,  but  this 
has  not  been  demonstrated.  If  the  fracture  is  compound  the  wound 
must  be  cleaned  and  protected,  and  advantage  may  be  taken  of  it  to 
do  whatever  the  condition  of  the  bone  requires,  but  this  cannot  be 
expected  to  have  any  important  influence  upon  the  progress  and  out- 
come of  the  injury. 

Certain  exceptional  forms  of  injury  require  separate  description. 

Possible  Fracture  of  the  Internal  Table. 

When  the  skull  has  been  contused  (compound)  by  a  blow  of  the 
kind  known  sometimes  to  produce  fracture  of  the  internal  table,  such 
as  a  glancing  bullet  or  a  sharp  blow  by  some  small  object,  there  can  be 
no  serious  objection  to  trephining  in  order  to  insure  cleanliness  and 
determine  the  condition  of  the  internal  table,  if  care  is  taken  not  to 
open  the  dura  ;  and  even  when  the  skin  is  not  broken,  if  well-marked 
symptoms  of  localized  cerebral  injury  are  present,  a  similar  interference 
would,  I  think,  be  justifiable  as  an  attempt  to  relieve  a  local  and 
limited  injury.  But,  I  repeat,  the  known  instances  of  fracture  of  the 
internal  table  alone  are  very  few,  and  almost  all  of  them  compound 
and  fatal  by  infection  through  the  scalp  wound.  If  it  is  claimed  that 
there  are  many  simple  (not  compound)  ones  which  pass  unrecognized 
because  the  patient  recovers,  it  must  be  added  that  that  then  is  proof 
that  an  operation  is  not  always  necessary.  The  diagnosis  of  probable 
fracture  of  the  internal  table  has  been  not  infrequently  made  for  no 
better  reason  than  that  no  other  could  be  positively  made.  Such  mis- 
takes would  be  less  frequent  and  officious  treatment  would  be  rarer  if 
the  fact  was  fully  appreciated  that  early  general  cerebral  symptoms 
mean  generalized  cerebral  lesions,  and  that  such  cannot  be  relieved  by 
local  measures.     For  the  latter  there  must  be  local  indications. 

Rupture  of  the  Middle  Meningeal  Artery. 

Rupture  of  the  middle  meningeal  artery  or  of  one  of  its  branches  by 
a  fracture  crossing  its  course,  or  even  without  fracture,  is  a  not  infre- 
quent injury  of  great  importance  and  requiring  immediate  operative 
relief.     As  the  vessel  lies  in  a  groove  on  the  inner  surface  of  the  bone 


FRACTURES  OF   THE  SKULL.  159 

and  is  covered  by  the  dura,  the  hemorrhage  commonly  takes  place 
between  the  dura  and  the  bone,  stripping  up  the  former  sometimes  for 
a  considerable  distance  and  causing  s;^Tnptoms  of  local  and  sometimes 
of  general  compression.  Usually  there  is  an  interval,  half  an  hour  to 
three  hours  (occasionally  very  much  longer,  even  eight  days  in  one  of 
Konig's  cases  and  four  and  nine  days  respectively  in  two  of  mine),  be- 
tween the  blow  and  the  development  of  the  symptoms,  an  interval 
during  which  the  patient  may  seem  entirely  well,  but  which  in  other 
cases  may  be  masked  by  the  symptoms  of  cerebral  injury  occasioned  by 
the  primary  violence  ;  the  recoguition  in  the  latter  case  nuist  then  come 
through  the  steady  increase  in  the  symptoms  and  frequently  the  limited 
paralyses  caused  by  pressure  upon  portions  of  the  motor  area.  The 
pulse  becomes  slow  (pulse  of  pressure),  and  the  pupils  unequal,  that  on 
the  side  of  the  injury  being  usually  dilated.  The  paralyses,  of  course, 
are  on  the  opposite  side  of  the  body  ;  if  limited  they  indicate  a  hemor- 
rhage between  the  dura  and  the  bone  ;  if  diffuse,  a  hemorrhage  into  the 
arachnoid  space. 

Left  to  itself  the  injury  terminates  fatally  in  the  great  majority  of 
cases.  Relief  must  be  given  by  removal  of  the  extravasated  blood 
and  arrest  of  the  bleeding.  The  difficulty  may  be  to  determine  the 
point  at  which  the  trephine  is  to  be  applied  to  meet  the  indications;  the 
guides  thereto  are  furnished  by  external  evidences  of  injury,  the  seat 
of  the  fracture,  the  situation  of  the  centres  corresponding  to  the  paral- 
yses, the  anatomical  relations  of  the  artery,  and  the  relative  frequency 
of  hemorrhage  at  different  points.  The  artery  runs  from  the  foramen 
spinosuni  across  the  middle  fossa  and  upward  along  the  greater  wing 
of  the  sphenoid  and  there  divides  into  two  branches.  The  most  fre- 
quent seat  of  rupture  and  hemorrhage  corresponds  to  the  lower  anterior 
portion  of  the  parietal  bone  (anterior  branch  of  the  artery) ;  the  next, 
but  much  less  frequent,  corresponds  to  the  lower  posterior  portion  of  the 
parietal  and  the  adjoining  portion  of  the  occipital  (posterior  branch). 

The  size  of  the  extravasation  varies  greatly  ;  I  have  seen  one  of  less 
tlian  an  ounce  directly  above  the  ear  in  which  the  symptoms — stupor 
and  limited  paralysis — were  well  marked  and  which  was  cured  by 
operation. 

If  the  exact  position  of  the  extravasation  cannot  be  determined  and 
if  no  indication  is  furnished  by  a  line  of  fracture  or  paralysis,  an  open- 
ing made  near  the  point  where  the  frontal,  parietal,  and  temporal  l)ones 
meet,  say  two  finger-breadths  above  the  zygoma  and  an  inch  behind 
the  external  angular  process  of  the  frontal,  will  expose  the  most  fre- 
quent seat  and  also  the  anterior  branches  of  the  artery.  An  ojiening 
about  three  inches  directly  behind  this  will  expose  the  posterior  region. 

The  opening  sliould  be  made  with  the  trephine  or  by  removing  a 
broken  fragment,  and  if  the  extravasation  is  not  at  once  encountered 
the  dura  should  be  carefully  separated  from  the  bone  in  different  direc- 
tions in  search  of  it.  When  found  the  blood  should  be  picked  or 
washed  out  if  clotted,  and  bleeding  points  should  be  secured  if  possi- 
ble, or,  failing  that,  the  wound  should  be  packed  in  their  neighborhood. 
The  artery  is  often  difficult  to  secure,  especially  when  its  point  of  imi[)- 
ture  is    not  within  the  opening    made  by  the  trcjthine.      renqxtnuy 


160  FRACTURES. 

pressure  with  the  finger,  an  artery  clamp,  or  even  a  pad  of  gauze  has 
been  successfully  employed.  In  all  my  own  cases  the  bleeding  has 
stopped  spontaneously  before  the  removal  of  the  clot. 

Perforating  Fractures  of  the  Base  through  the  Orbit. 

Perforating  fractures  of  the  base  through  the  orbit  are  extremely  grave 
and  rarely  accessible  to  treatment,  the  important  lesions  being  usually 
that  of  the  brain.  In  the  extent  of  these  lesions  and  their  consequences 
the  variations  are  very  great.  I  have  seen  the  breech-piece  of  a  shot 
gun,  about  six  inches  long,  driven  into  the  brain  through  the  nose  and 
orbit  and  carried  there,  unrecognized,  for  more  than  two  months,  the 
patient  recovering  sufficiently  to  take  a  railway  trip  to  the  city  in 
order  to  have  the  deformity  of  his  face  relieved;  and  in  another  a 
single  birdshot  which  entered  just  above  the  tendo  oculi  and  passed 
through  the  lower  part  of  the  frontal  lobe  directly  back  nearly  to  the 
Sylvian  fissure  caused  death  in  a  week  without  any  evidence  of  inflam- 
mation and  with  only  a  minute  intracranial  hemorrhage.  Sometimes 
an  important  feature  is  the  wounding  of  the  cavernous  sinus  or  of  a 
large  artery.  Another,  and  frequent  one,  is  the  infection  of  the  deeper 
portion  of  the  wound  by  the  vulnerant  body  even  if  the  superficial 
portion  of  the  wound  is  small  and  heals  kindly.  The  common  cause 
is  the  passage  of  a  small  body — a  bullet,  cane,  pencil — through  or  even 
between  the  eyelids.  I  have  seen  two  cases  in  which  a  slender  stick 
(the  end  of  an  umbrella  in  one)  had  thus  penetrated  and  had  broken 
off;  both  patients  died,  one  after  removal  to  another  hospital  and  opera- 
tion there  by  the  large  omega-flap  to  expose  the  base  of  the  brain,  pro- 
fuse venous  bleeding  which  could  not  be  arrested  was  encountered  and 
the  patient  died  shortly  after  removal  from  the  table. 

Similar  wounds  through  the  nose  and  mouth  are  even  more  exposed 
to  infection. 

Summary. 

The  principles  of  treatment  may  be  thus  summarized  :  Danger  to  life 
and  function  comes  mainly  from  generalized  contusion  of  the  brain, 
large  or  small  intracranial  hemorrhages,  and  intracranial  infection 
through  an  open  wound ;  the  fracture  itself,  as  such,  even  when  asso- 
ciated with  depression,  is  rarely  a  factor  in  the  fatal  result. 

Against  generalized  cerebral  injury  the  only  treatment  is  medical — 
rest,  sedatives,  laxatives,  cold  to  the  head,  unless  experience  should  con- 
firm the  value  of  Cushing's  decompression.  Against  infection  we  have 
prevention  and  disinfection ;  after  it  is  fairly  established  disinfection 
and  drainage  have  a  restricted  availability.  Consequently,  fractures 
of  the  base  and  fissured  fractures  of  the  vault  not  compound  do  not 
require  operation.  When  compound,  the  Avound  may  be  enlarged  suf- 
ficiently to  permit  disinfection  of  the  area  already  exposed  to  infec- 
tion; and  for  the  purpose  of  this  disinfection  a  fissure  may  be  enlarged, 
but  this  enlargement  should  not  be  carried  much  beyond  the  limits  of 
the  original  wound. 


FRACTURES  OF   THE  SKVLL.  101 

Depression  of  a  portion  of  the  skull  below  its  normal  level  is  not  a 
condition  which  always  needs  to  be  corrected.  The  associated  condi- 
tions which  indicate  its  correction  are  limited  paralyses  or  localized  irri- 
tation due  to  pressure  of  the  depressed  portion  upon  the  undei'lying 
portion  of  the  brain.  Conditions  which  justify  its  correction  are  an 
associated  wound  of  the  scalp  and,  in  simple  fractures  with  a  well- 
defined  small  area  of  depression,  the  absence  of  symptoms  of  general- 
ized injury  of  the  brain  and  consequently  of  fissures  radiating  from  the 
depressed  area  which  would  favor  the  extension  of  infection  if  it  should 
occur  in  the  wound  made  for  the  relief  of  the  depression. 

Epidural  or  subdural  hemorrhage  (rupture  of  the  middle  meningeal 
artery)  requires  operation  for  the  i^emoval  of  the  extravasated  blood 
and  the  arrest  of  hemorrhage. 

A  monoplegia  promptly  following  a  blow  upon  the  head  is  an  indi- 
cation for  the  application  of  the  trephine  over  the  corresponding  cor- 
tical centre,  with  the  expectation  of  thereby  removing  a  clot  or  a 
fragment  which  is  making  pressure  on  that  portion  of  the  brain. 

Late  functional  cerebral  disturbances  (epilepsy,  etc.)  appear  to  be 
so  much  more  closely  connected  with  injury  of  the  brain  and  meninges 
which  cannot  be  corrected  by  a  primary  operation  than  with  traumatic 
irregularities  on  the  inner  surface  of  the  skull  which  can  be  thus  cor- 
rected, that  an  early  operation  for  their  prevention  is  not  indicated. 

Severe  meningeal  or  cortical  inflammation,  not  connected  with  an 
external  wound,  is  so  rare  that  operation  for  its  prevention  is  not  indi- 
cated, and  is,  indeed,  more  likely  to  produce  it  than  to  prevent  it. 


CHAPTEK  XL 

FEACTURES  OF    THE  VERTEBRAE. 

Fractures  of  the  vertebrae  have  this  in  common  with  fractures  of 
the  skull,  that  most  of  their  importance  depends  upon  the  associated 
injury  of  the  nerve-centres  and  trunks  contained  within  their  canal, 
but  they  have  in  addition  the  importance  due  to  the  function  of  the 
spine  as  a  support  for  the  head  and  trunk.  Upon  the  integrity  of  this 
support  depend  not  only  the  power  of  locomotion,  but  also  grace  of 
carriage  and  dexterity  in  the  use  of  the  limbs. 

The  spinal  cord,  occupying  the  centre  of  the  vertebral  column,  is 
efficiently  protected  against  any  external  violence  that  is  not  sufficient 
to  break  the  bones  that  constitute  the  latter,  or  the  ligaments  and  mus- 
cles that  bind  those  bones  together ;  and  the  column  itself  is  constituted 
in  a  manner  that  combines  elasticity  and  mobility  with  the  necessary 
firmness  and  rigidity.  The  bodies  of  the  vertebrae,  increasing  in  size 
from  above  downward  in  correspondence  with  the  variations  in  the 
weight  and  strain  which  the  different  ones  are  called  upon  to  bear,  are 
composed  of  spongy  tissue  and  separated  from  each  other  by  the  elastic 
intervertebral  cartilages,  and  prevented  from  changing  their  positions 
by  the  interlocking  of  the  articular  processes  upon  the  sides.  The 
general  form  of  the  column  is  that  of  a  long  slender  cone  with  a  double 
antero-posterior  curve,  and  its  component  parts  are  strongly  bound 
together  by  ligaments  and  muscles  allowing  a  range  of  motion  which, 
while  small  between  each  pair  of  vertebrae,  is  in  the  aggregate  consid- 
erable. Mechanically,  therefore,  the  spine  is  exposed  to  fracture  by 
direct  violence,  like  other  bones,  and  by  indirect  violence  through 
exaggeration  or  straightening  of  its  normal  curves. 

In  the  displacements  following  fracture  the  corresponding  joints  may 
be  dislocated,  and  as  in  dislocation  there  may  be  associated  fracture,  and 
as  the  symptoms  in  the  two  forms  of  injury  are  in  many  respects  the  same, 
they  are  sometimes  grouped  as  "fracture-dislocations"  of  the  spine. 

Fractures  of  the  vertebrae  are  relatively  rare,  0.5  per  cent,  in  my 
statistics  (Chapter  I.).  Gurlt  collected  270  cases,  with  444  fractures, 
and  found  that  fractures  of  the  cervical  aud  dorsal  vertebrae  are  about 
equally  frequent,  178  and  184  respectively,  while  those  of  the  lumbar 
vertebrae,  82,  are  much  less  common ;  that  the  fatal  cases  of  fracture 
of  the  cervical  vertebrae  are,  however,  considerably  more  numerous, 
actually  and  relatively,  than  those  of  the  two  other  regions  ;  that  the 
fifth  and  sixth  cervical,  the  last  dorsal,  and  the  first  lumbar  are  more 
frequently  broken  than  any  of  the  others  ;  and  that  it  is  common  in 
fractures  of  the  cervical  and  dorsal  regions  for  more  than  one  vertebra 
to  be  broken  at  the  same  time.  They  are  extremely  rare  in  childhood 
and  old  age,  and  relatively  infrequent  in  women. 
(162) 


FRACTURES  OF  THE  VERTEBRA. 


163 


The  part  most  frequently  fractured  is  the  body  of  the  vertebra — 
that  is,  in  about  two-thirds  of  all  cases,  or  in  more  than  half  of  the 
fractures  of  the  cervical  vertebrae,  in  about  seven-eighths  of  those  of 
the  dorsal  vertebrae,  and  in  about  all  those  of  the  lumbar  vertebne. 
Or,  in  general  terms,  fractures  of  the  bodies  of  the  vertebrae  begin  at 
about  the  middle  of  the  cervical  region  and  increase  in  frequency  down- 
ward. Simultaneous  fracture  of  two  or  more  vertebrae  is  conmion  in 
the  cervical  and  upper  dorsal  regions,  less  common  in  the  lower  dorsal, 
and  rare  in  the  lumbar  region.  Fracture  of  one  or  more  of  the  ver- 
tebral processes  either  of  the  same  or  of  adjoining  vertebne  is  connnon. 


Pathology. 

The  fracture  of  the  body  of  a  vertebra  may  be  complete  or  incom- 
plete; the  line  of  fracture  may  extend  only  partly  through  it  or  en- 
tirely across  it,  or  it  may  be  broken  into  several  fragments,  or  com- 
pressed, or  impacted.  The  line  of  fracture,  if  single,  may  be  vertical, 
horizontal,  or  oblique  in  any  direction  ;  the  first  being  found  almost 
exclusively  in  the  cervical  and  upper  dorsal  regions,  the  two  latter 
and  multiple  fractures  occurring  everywhere.  The  transverse  and 
oblique  fractures   lie,    as   a  rule,    nearer   the    upper   than   the   lower 


Fig.  77. 


Fig.  78. 


Transverse  fracture  of  vertebra. 


Displacement  of  the  vertebrrc  causing  coniprcssion 
of  the  spinal  cord. 


border  of  the  bone,  and  may  pass  from  the  upper  to  the  anterior  sur- 
face, leaving  the  posterior  and  lower  surfaces  unbroken,  and  in  the.'^e 
cases  the  upper  fragment  preserves  its  relations  to  the  overlying  ver- 
tebra and  is  displaced  with  it  forward  and  downward,  producing  a 
change  in  the  long  axis  of  the  spine  characterized  by  an  angle  having 
its  apex  directed  backward  at  the  seat  of  fracture.  This  displnccmcnt 
narrows  the  antero-posterior  diameter  of  the  spinal  canal  and  lacerates 
or  compresses   the  spinal  cord  within   it.       If  the  line  of  fracture  is 


164 


FRACTURES. 


Fig.  79. 


oblique,  and  if  fracture  or  dislocation  of  the  articular  processes  is  asso- 
ciated with  it,  tlie  displacement  is  inclined  to  tlie  corresponding  side 
either  directly  or  by  rotation. 

Compression  of  the  body  of  a  vertebra  is  found  either  in  combina- 
tion with  comminuted  fracture  or  alone,  and  involving  one  or  several 

vertebrae.  It  is  apparently  caused  by 
forcible  forward  flexion,  in  which  either 
the  posterior  portions  of  the  vertebrae 
mu.st  separate  from  each  other  or  the 
anterior  portions  must  approximate  by 
condensation  of  the  intervertebral  disks 
or  of  the  bone. 

The  compression  may  be  so  extreme 
that  the  intervertebral  disks  above  and 
below  the  affected  vertebra  are  brought 
into  contact  with  each  other  in  front, 
the  substance  of  the  bone  being  partly 
compressed  and  partly  forced  out  upon 
the  sides  or  behind  into  the  spinal  canal 
(Figs.  80  and  81),  compressing  the  cord. 
With  this  compression  may  be  associ- 
ated fracture  or  fissure  of  the  body,  and 
especially  fracture  of  the  processes  of 
the  same  or  the  adjoining  vertebra.  The  same  shortening  of  the 
anterior  portion  of  the  body  may  be  produced  by  splintering  of  part 
of  the  bone  or  by  impaction  of  one  fragment  into  another  lying  above 


Compression  of  the  last  dorsal  vertebra. 


Fig.  80. 


Fig.  81. 


Fracture  with  compression  of  the  third  and  fourth  lumbar  vertebrfe. 


or  below  it.     The   intervertebral   disk  may  be   partly  squeezed  out, 
bringing  with  it  a  scale  of  bone  from  either  or  both  vertebne. 

Fracture  of  the  vertebral  arches,  according  to  Gnrlt,  is  found  in  about 
half  the  cases  of  fracture  of  the  cervical  \ertebrfe,  and  only  in  one- 
seventh  of  those  of  the  dorsal,  and  one-eighth  oftho.se  of  the  lumbar.^ 

'  For  cases  of  doubtful  character  in  the  lumbar  vertebrae,  see  section  on  Course  and  Ter- 
minations, 


FRACTURES  OF  THE   VERTEBRAE.  165 

He  attributes  the  frequency  of  tliis  form  of  fracture  in  the  cervical 
spine  to  the  comparatively  greater  breadth  and  less  height  of  the  arch 
and  to  the  absence  of  that  protection  which  is  furnished  in  the  dorsal 
and  lumbar  regions  by  the  larger  and  stronger  spinous,  transverse,  and 
oblique  processes.  When  the  arch  is  broken  on  each  side  the  interme- 
diate portion  l)earing  the  spinous  process  may  be  driven  into  the  spinal 
canal  and  cause  fatal  laceration  or  compression  of  the  cord.  Gurlt's 
statistics  contain  six  such  cases,  aifecting  the  fifth,  sixth,  and  seventh 
cervical  vertebrae. 

The  spinous  processes  are  broken  most  frequently  at  those  points 
where  they  are  longest  and  thinnest,  nearly  one-fourth  of  the  cases 
occurring  in  the  cervical  spine,  more  than  half  in  the  dorsal,  and 
about  one-eighth  in  the  lumbar  ;  and  often  several  adjoining  ones 
are  broken  at  the  same  time.  In  the  dorsal  region  this  fracture  is 
usually  found  only  in  combination  with  fracture  of  the  body  of  one 
of  the  vertebrse  above  or  below  it.  Isolated  fracture  of  a  spinous 
process  may  occur  as  the  result  of  direct  violence,  or  of  muscular 
action,  and  the  displacement  is  either  directly  dow^nward  or  to  one  side. 

Fracture  of  the  transverse  or  articular  processes  occurs  in  combina- 
tion with  other  fractures  in  about  one-sixth  of  all  cases,  but  is  rare 
except  in  such  combination.  In  a  few  instances  in  which  it  has 
occurred  alone  it  was  the  result  of  gunshot  injury.  As  a  complication 
of  other  fractures  the  proportion  of  its  occurrence  for  the  transverse 
process  is  greatest  in  the  cervical  and  next  in  the  lumbar  and  dorsal 
regions  ;  for  the  articular  processes  it  is  greatest  in  the  cervical  and 
smallest  in  the  lumbar,  Fracture  of  a  transverse  process  of  a  dorsal 
vertebra  may  lead  to  fracture  of  the  rib  which  articulates  with  it,  and 
fracture  of  the  transverse  process  of  a  cervical  vertebra  may  seriously 
injure  the  vessels  contained  in  the  vertebral  canal.  Fracture  of  an 
articular  process  exposes  to  dislocation  of  the  vertebra  with  all  its 
accompanying  dangers.  The  transverse  processes  of  the  lumbar  ver- 
tebrse may  apparently  be  broken  by  muscular  action,  the  contraction  of 
the  psoas,  longissimus  dorsi,  and  quadratus  lumborum.  A  diagnostic 
symptom  is  said  by  Tanton  ^  to  be  localized  pain  on  lifting  the  leg 
while  recumbent. 

The  ligaments  which  bind  the  diiferent  vertebrse  together  are  torn 
in  fracture  to  an  extent  which  varies  with  the  severity  of  the  injury 
and  the  degree  of  the  displacement,  and  the  intervertebral  disks  may 
be  torn,  displaced,  or  compressed.  In  rare  cases  the  injury  may  be 
confined  to  the  ligaments  and  disks — real  dislocation  or  diastasis  with- 
out fracture — although  tlie  distinction  cannot  be  made  during  life. 

The  spinal  cord,  the  diameter  of  which  is  considerably  less  than  that 
of  the  canal  in  which  it  lies,  is  suspended  within  the  dura  mater,  which 
is  itself  loosely  connected  with  the  bones  and  separated  from  direct  con- 
tact with  them  in  most  places  by  a  rich  venous  ])lexus.  The  medul- 
lary portion  of  the  cord  ends  at  the  first  or  second  lumbar  vertel)ra,  and 
its  lower  portion  is  enveloped  by  the  numerous  nerve  trunks  which 
pass  downward  to  form  the  cauda  equina  and  the  lumbar  and  sacral 
plexuses.  The  cord  is  injured  directly  only  when  the  knnen  of  the 
canal  is  considerably  encroached  upon  by  the  displacement  of  a  frag- 
'  Tanton :  Rev,  de  Cbirurgie,  1910,  vol.  xlii.  p.  1101,. 


166  FRACTURES. 

ment  or  of  a  vertebra,  but  it  can  be  compressed  by  extravasated  blood 
or  by  inflammatory  exudations,  or  torn  by  elongation.  I  have  seen 
it  so  injured  in  fracture  of  both  laminae  of  the  sixth  cervical  without 
displacement,  by  anterior  flexion  of  the  neck,  as  to  cause  immediate 
paraplegia  and  death  in  a  week.  Occasionally  the  cord  is  penetrated 
-by  a  sharp  fragment,  but  usually  the  dura  mater  is  untorn  and  the  cord 
is  crushed  between  the  anterior  portion  of  one  fragment  or  vertebra, 
usually  the  lower,  and  the  posterior  portion  of  another,  usually  the 
upper.  This  crushing  presents  all  degrees,  from  a  slight  flattening  to 
complete  disorganization,  and  apparently  the  medullary  portion  is  more 
easily  and  permanently  injured  and  destroyed  than  the  nerve-fibres  in 
the  columns  beside  it. 

Hemorrhage,  Hsematomyelia.  Hemorrhage,  without  division  of  the 
cord,  may  be  extra-  or  intra-dural,  or  within  the  substance  of  the  cord 
(hsematomyelia).  Hemorrhage  outside  the  cord  spreads  upward  and 
downward  w^ithin  the  canal  and  produces  changes  and  symptoms  by 
pressure  upon  the  cord. 

Hsematomyelia  is  apparently  caused  by  forcible  elongation  of  the 
cord  in  hyperflexion  or  extension  of  the  column,  with  or  without  recog- 
nizable lesion  of  the  ligaments  or  bones ;  it  is  seen  almost  exclusively 
in  the  lower  cervical  and  upper  dorsal  region,  but  sometimes  near  the 
junction  of  the  lower  dorsal  and  lumbar  regions.  The  condition,  first 
pointed  out  by  Thorburn  and  Minor,  of  Moscow,  about  1890,  has 
been  recently  studied  in  detail  by  Bailey^  and  Bolton,^  The  hemor- 
rhage takes  place  in  the  gray  matter  of  the  cord  and  may  be  very 
closely  limited  to  it,  spreading  upward  and  downward  in  it  through 
two,  three,  or  even  more  segments.  If  the  lesion  is  more  severe  the 
hemorrhage  may  extend  into  the  white  columns  as  a  clot,  or  appear 
there  as  punctate  extravasations.  If  the  patient  survives  the  blood 
is  absorbed,  leaving  cavities  within  the  cord  which  contain  a  viscid 
liquid  and  tend  toward  obliteration  by  formation  of  connective  tissue. 
The  elements  of  the  gray  matter,  cells  and  fibres,  which  are  injured  by 
the  hemorrhage  appear  to  be  incapable  of  repair  with  restoration  of 
function,  but  pressure-effects  upon  adjoining  parts  may  be,  and  ap- 
parently frequently  are,  recovered  from.  Consequently,  the  recogni- 
tion of  the  condition  is  of  great  importance  in  prognosis  and  in  deter- 
ring from  active  surgical  interference.  Apparently  most  of  the  cases 
of  injury  to  the  neck  which  recover  after  having  presented  symptoms 
of  severe  injury  to  the  cord  are  cases  of  hsematomyelia.  In  a  notable 
number  of  them  the  injury  has  been  caused  by  diving  into  shallow 
water,  the  head  being  thrown  forcibly  back  to  avoid  contact  with  the 
bottom. 

Etiology. 

The  immediate  causes  are  muscular  action  and  external  violence. 
The  former  is  very  rare  and  acts  either  by  a  direct  pull  of  the  muscle 
upon  the  process  to  which  it  is  attached  or  by  the  momentum  given 
by  the  head  in  sudden  dorsal  flexion  of  the  neck  or  rotation  of  the 
head.     The  most  frequent  examples  of  the  latter  (producing  either 

1  Bailey  :  Med.  Record,  Nov.  19,  1898.  ^  Bolton  :  Annals  of  Surg.,  Aug.,  1899. 


FRACTURES   OF  THE    VERTEBRM  107 

fracture  or  dislocation  of  the  cervical  spine)  have  been  in  cases  in 
which  the  patient  has  dived  into  shallow  water  and  has  thrown  liis 
head  backward  to  escape  contact  with  the  bottom. 

The  commonest  cause  is  the  forcible  bending  of  the  spine  in  a  fall 
or,  less  frequently,  by  the  weight  of  a  falling  object  or  by  the  com- 
pression of  the  body  in  a  narrow  space,  as  in  driving  under  an  archway 
(indirect  fracture).  The  relative  frequency  of  the  injury  at  the  lower 
part  of  the  cervical  spine  and  at  the  junction  of  the  dorsal  and  lumljar 
segment  seems  to  be  associated  with  the  fact  that  at  these  points  the 
more  flexible  and  the  more  rigid  portions  of  the  column  meet,  such 
meeting  points  being  specially  liable  to  break  in  all  combinations  of 
flexible  and  rigid  bodies. 

Fractures  by  direct  violence  are  infrequent  and  are  usually  found  in 
the  posterior  portion  of  the  vertebra. 

Symptoms  and  Diagnosis. 

(See  also  Dislocations  of  the  Vertebrae.) 

The  symptoms  of  fracture  of  the  spine  vary  with  the  position  and  the 
portion  of  the  vertebra  involved,  and  therefore  need  a  separate  and 
detailed  consideration  in  connection  with  the  diiferent  groups  of  frac- 
tures. But'  there  are  certain  general  symptoms  commbn  to  most  which 
may  first  be  mentioned.  After  the  first  shock  of  the  injury,  which  usually 
passes  off  without  permanent  impairment  of  the  intelligence,  the  patient 
complains  of  a  localized  pain  at  the  seat  of  fracture  increased  by  manip- 
ulation or  movements.  There  is  usually  a  recognizable  deformity  con- 
sisting of  a  change  in  the  direction  of  the  spine,  a  more  or  less  marked 
angular  projection  backward  with  or  without  swellingof  the  surround- 
ing soft  parts  ;  crepitus  can  sometimes  be  made  out  by  the  surgeon,  but 
more  commonly  it  is  appreciable,  if  at  all,  only  by  the  patient  himself 
when  his  body  is  moved.  The  most  important  and  constant  symptom 
is  paralysis,  motor  and  sensory,  more  or  less  complete,  of  the  limbs  and 
the  portion  of  the  body  lying  below  the  fracture.  If  complete  its 
upper  limit  is  usually  sharply  defined  by  a  line  crossing  the  trunk  and 
corresponding  to  the  adjoining  limits  of  the  regions  supplied  by  the 
nerves  that  leave  the  column  immediately  above  and  bo]o\\'  the  ]ioiiit 
at  which  the  cord  has  been  injured.  The  consequences  of  this  paralysis, 
if  it  involves  the  abdominal  muscles,  bladder,  and  rectum,  are  reten- 
tion of  urine  and  feces,  followed  by  incontinence  of  one  or  both,  by 
alkaline  fermentation  of  the  former,  and  cystitis.  Respiratory  diffi- 
culties, sometimes  severe  enough  to  cause  death,  appear  when  the  frac- 
ture involves  the  upper  portion  of  the  spine,  the  result  of  the  i)aralysis 
either  of  the  abdominal  muscles  or  of  the  diaphragm,  or  of  vasomotor 
injury.  There  is  also  a  great  tendency  to  sloughing  at  all  points  of 
])ressure  within  the  paralyzed  region,  especially  over  the  sacrum  and 
trochanters  and  along  the  back.  The  sloughs  a})pcar  promptly,  some- 
times within  two  or  three  days,  are  usually  symmetrical,  and  often 
hasten  death  even  if  they  are  not  its  inimcdiate  cause. 

Paralysis  is,  of  course,  only   a  sym})tom  of  injury  to  the  cord  and 


168  FRACTURES. 

may  follow  violence  that  has  caused  neither  fracture  nor  dislocation. 
Thus,  a  diastasis  of  two  vertebrse,  followed  by  immediate  return  to 
their  normal  relations,  may  cause  hemorrhage  into  the  canal  or  may 
even  injure  the  cord  by  elongation  and  thus  cause  paralysis.  A  paral- 
ysis appearing  shortly  after  an  injury,  and  increasing,  generally  indi- 
cates hemorrhage  into  the  canal,  but  I  have  seen  it  caused  by  displace- 
ment, with  pressure,  occurring  during  the  transfer  of  the  patient  to 
hospital,  the  condition  being  shown  by  autopsy. 

Extension  of  paralysis  indicates  hemorrhage  or  an  ascending  mye- 
litis. 

In  haematomyelia  there  is  immediate  motor  paralysis  (usually  para- 
plegia, but  occasionally  hemiplegia,  when  only  one  gray  column  is 
affected)  which  is  transient  except  for  those  muscles  whose  spinal 
nuclei  in  the  gray  matter  have  been  destroyed  by  the  hemorrhage. 
Thus,  when  the  lesion  is  situated  in  the  lower  cervical  region  the  paral- 
ysis of  the  lower  limbs  and  the  sphincters  promptly  disappears,  but 
that  of  the  muscles  of  the  forearm  and  hand  remains  in  part.  The 
interference  with  sensation  is  constant  and  characteristic  :  there  is  loss 
of  sensibility  to  heat  and  cold  (thermo-ansesthesia)  and  usually  insensi- 
bility to  pain  (analgesia)  also,  but  tactile  sensibility  is  not  aifected. 
Bailey  says  the  distribution  of  these  disturbances  is  the  same  as  that 
of  the  angesthesia  of  a  corresponding  transverse  lesion  of  the  cord,  but 
that  it  may  present  the  Brown-Sequard  type,  namely,  motor  paralysis 
of  one  arm  and  leg  with  loss  of  pain-sense  and  temperature-sense  in 
the  arm  and  leg  of  the  opposite  side.  The  tendency  is  toward 
improvement,  and  sometimes  recovery  is  complete.  The  reflexes  are  at 
first  lost,  then  slowly  regained.      " 

In  complete  transverse  injury  there  is  permanent  complete  paraplegia 
and  loss  of  all  kinds  of  sensation  and  of  the  reflexes. 

In  incomplete  transverse  injury  there  is  irregular  paraplegia,  the 
sensibility  to  pain,  touch,  and  temperature  may  persist  or  be  regained 
in  limited  areas  below  the  lesion,  and  the  reflexes  return  and  become 
exaggerated. 

Priapism,  more  or  less  complete,  was  observed,  according  to  Gurlt, 
in  31  of  96  cases  of  fracture  of  the  cervical  and  two  upper  dorsal  ver- 
tebrse, 16  times  in  133  cases  of  fracture  between  the  third  dorsal  and 
second  lumbar  vertebrse,  and  never  in  fracture  below  tlie  latter.  It 
appears  promptly,  usually  on  the  first  or  second  day,  and  seldom  lasts 
longer  than  a  fortnight.  Notwithstanding  the  insensitiveness  of  the 
penis  it  may  be  caused  or  increased  by  the  use  of  the  catheter.  On  the 
other  hand,  in  one  case  the  erect  organ  became  relaxed  as  soon  as  the 
catheter  had  passed  over  half  the  length  of  the  urethra.  Ejaculations 
are  very  exceptional,  there  being  only  four  instances  in  Gurlt's  collec- 
tion, all  of  them  in  cases  of  fracture  of  the  cervical  spine. 

Fracture  of  Atlas  and  Axis. 

The  intimate  relations  existing  between  these  two  bones  and  the 
medulla  oblongata,  and  their  position  above  the  roots  of  the  phrenic 
nerve   as  well  as   above  those  of  the  other  nerves  supplying  other 


FRACTURES  OF  THE    VERTEBRA. 


169 


Fig.  82. 


muscles  which  aid  in  respiration,  make  their  injury  especially  danger- 
ous, and  have  probably  led  to  the  generally  received  opinion  that  their 
fracture  is,  as  a  rule,  immediately  fatal.  Gurlt's  cases  show,  however, 
that  this  opinion  is  not  correct,  for  in  the  eleven  in  which  the  nature 
of  the  injury  was  demonstrated  by  the  autopsy,  death  occurred  imme- 
diately in  only  two,  and  in  only  two  others  within  an  hour  after  the 
injury  was  received.  In  the  other  cases  the  patients  survived  for  a 
considerable  length  of  time,  thirteen  days  in  one,  although  some  of 
them  at  the  last  died  suddenly,  apparently  by  displacement  of  the  ver- 
tebree  due  to  incautious  movements.  The  fractures  were  all  caused  by 
external  violence,  sometimes  slight,  as  a  fall  from  the  bed  while  trying 
to  reach  down  to  the  floor. 

The  parts  broken  in  ten  of  these  eleven  cases  were  :  the  odontoid 
process  alone  once  ;  the  odontoid  process  and  posterior  arch  of  the  atlas 
three  times  ;  the  posterior  arches  of  the 
atlas  and  axis  three  times  ;  the  poste- 
rior arch  of  the  axis  alone  once ;  the 
spinous  process  of  the  axis  twice.  In 
six  of  the  cases  there  was  associated 
fracture  of  other  cervical  or  dorsal  ver- 
tebrae, and  in  no  case  was  the  trans- 
verse ligament  torn.  Figure  82,  taken 
from  a  specimen  in  the  museum  at 
Braunschweig,  shows  a  fracture  of  the 
superior  articular  surface  of  the  axis. 
The  patient  was  twenty-four  years  old, 
and  died  in  a  few  hours  after  falling 
out  of  a  wagon  upon  his  head. 

The  symptoms  of  this  fracture  are 
«o  variable  and  so  indefinite  and  have 
so  much  in  common  with  simple  dis- 
location of  one  bone  upon  the  other, 
or  of  the  atlas  upon  the  skull,  that  the  diagnosis  is  extremely  diffi- 
cult. On  the  one  hand,  the  patient  may  die  instantly  ;  on  the  other, 
he  may  survive  a  longer  or  shorter  time,  either  completely  paralyzed 
or  presenting  no  important  symptoms,  and  then  die  suddenly  by  dis- 
placement of  the  fragments  or  gradually  by  extension  of  the  symp- 
toms, or  in  consequence  of  other  injuries,  or,  if  the  diagnosis  in  some 
such  cases  may  be  accepted,  may  even  get  well.  The  sym])toms  of 
local  pain  and  stiifness  of  the  neck  are  too  indefinite  to  be  of  any  ser- 
vice, and  paralytic  symptoms  may  be  entirely  absent,  as  in  Gurlt's 
second  case,  where  the  patient  walked  for  two  hours  after  the  accident  to 
reach  home  and  developed  no  paralysis  until  the  following  day.  Death 
took  place  suddenly  on  the  eighth  day,  and  the  autopsy  showed  fracture 
of  both  arches  of  the  atlas  and  of  the  odontoid  process. 

The  symptoms  in  those  of  Gurlt's  eleven  cases  which  survived  long 
enough  to  present  any,  or  in  which  any  are  recorded,  were  complete 
paralysis  of  all  the  parts  below  the  fracture  in  some,  partial  paralysis 
in  others,  only  a  slight  diminution  of  sensibility  in  the  left  arm  in  one, 
pain  in  the  neck  or  occiput  in  six,  rigidity  of  the  neck  in  most,  absence 
12 


Fracture  through  the  superior  articular 
surfaces  of  the  axis.    (Gt^rlt.) 


170  FRACTURES. 

of  recognizable  deformity  in  all^  distinct  crepitus  in  one,  and  falling 
forward  of  the  head  upon  the  breast  in  one.  All  of  these  symptoms 
— pain,  rigidity,  paralysis,  sudden  death — may  be  the  result  of  dislo- 
cation as  well  as  of  fracture,  and,  as  dislocation  has  in  addition  no 
general  or  local  characteristic  symptoms  which  serve  to  distinguish  it, 
the  differential  diagnosis  must  usually  remain  in  doubt. 

Fractures  of  the  Lower  Five  Cervical  and  First  Two  Dorsal  Vertebrae. 

The  special  characteristics  of  fractures  of  this  region  are  due  to  the 
inclusion  within  it  of  the  roots  of  the  phrenic  nerve  and  brachial  plexus. 
The  former  passes  out  through  the  intervertebral  foramen  between  the 
third  and  fourth  cervical  vertebrae,  either  coming  from  the  fourth  cer- 
vical pair  alone,  or  receiving  branches  also  from  the  third  and  fifth 
pairs.  The  brachial  plexus  is  formed  by  the  four  lower  cervical  and 
the  first  dorsal  pairs.  Consequently,  if  the  fracture  is  accompanied  by 
displacement  of  the  fragments  and  injury  to  the  spinal  cord,  paralysis 
of  the  upper  limbs  also  is  caused,  and  if  the  fracture  is  high  enough 
in  the  region  to  involve  the  phrenic  nerve  directly  or  by  extension 
death  follows  promptly,  preceded  by  the  respiratory  symptoms  peculiar 
to  lesion  of  this  nerve. 

Here,  too,  as  after  fracture  of  the  altas  and  axis,  are  found  cases  in 
which  the  patients  present  only  symptoms  of  paralysis  for  a  longer  or 
shorter  time,  and  then  die  suddenly  of  asphyxia  in  consequence  of  some 
accidental  or  intentional  movement  of  the  head,  which  probably  causes 
compression  of  the  phrenic  nerves  by  displacement  of  the  fragments. 

The  paralysis  in  fractures  of  the  portion  of  this  region  below  the 
fourth  cervical  vertebra  shows  many  variations.  From  the  relations 
of  this  part  to  the  brachial  plexus  it  might  be  expected  that  paralysis 
of  the  upper  limbs  would  be  a  constant  symptom,  excluding  those  cases 
in  which  there  is  no  displacement,  but  Gurlt's  tables  show  this  paral- 
ysis to  have  been  present  in  less  than  one-fourth  of  the  cases,  that  in 
the  majority  complete  paralysis  of  the  lower  portion  of  the  body 
extended  upward  at  first  only  to  the  middle  of  the  breast,  the  second 
rib,  rarely  to  the  neck,  clavicle,  or  shoulders,  and  sometimes  not  even 
to  the  umbilicus,  although  it  often  advanced  to  a  higher  point  later  in 
the  progress  of  the  case.  Paralytic  symptoms  appeared  in  the  arms, 
as  a  rule,  either  later  on  the  day  of  the  accident  or  on  the  following 
day.  The  paralysis  may  be  complete  in  one  arm  and  partial  or  absent 
in  the  other  ;  it  may  be  complete  of  mr)tion  and  incomplete  of  sensa- 
tion, or  the  reverse;  it  may  be  limited  to  the  arm  or  to  the  forearm  : 
or  the  injury  to  the  nerves  may  be  evidenced  by  abnormal  sensations, 
such  as  numbness  or  prickling  in  the  limb.  Probably  incompleteness 
of  paralysis  is  due  in  most  cases  to  the  conservation  of  some  of  the 
nerve  fibres,  although  the  medullary  position  of  the  cord  is  completely 
destroyed  by  crushing.  Hyperaesthesia  affecting  the  whole  or  part 
of  the  limb  is  occasionally  observed,  and  is  sometimes  associated  M"ith 
sharp,  lancinating,  continuou,s  or  intermittent  pain,  which  may  be 
spontaneous  or  may  be  excited  or  increased  by  the  slightest  touch  of 
the    surface.      Tonic    or    clonic    spasms   are    seen   somewhat    more 


FRACTURES   OF  THE   VERTEBRjE.  171 

frequently  thau  hyperesthesia,  sometimes  limited  to  the  arms  alone, 
sometimes  involving  other  muscles  also. 

An  important  consequence  of  the  paralysis  is  the  change  in  the 
respiratory  act  due  to  the  withdrawal  of  the  aid  of  the  accessory  mus- 
cles when  the  phrenic  nerve  is  uninjured.  As  a  consequence  of  the 
paralysis  of  the  intercostal  and  abdominal  muscles,  inspiration  is 
effected  by  the  diapliragm  alone,  and  expiration  l)y  the  weight  of  the 
abdominal  walls  and  viscera  which  sink  back  to  the  positions  from 
which  they  have  been  displaced  by  the  contraction  of  the  diaphragm. 
As  the  expiration  is  thus  purely  passive  the  patient  cannot  sneeze  or 
cough  strongly,  and  as  he  is  thus  prevented  from  clearing  his  lungs 
of  the  mucus  M^hich  collects  in  them  it  gives  rise  to  plentiful  moist 
rales.  If  the  phrenic  nerve  shares  in  the  injury  the  diaphragm  acts 
very  slowly,  perhaps  not  oftener  than  twice  or  thrice  in  the  minute, 
the  breathing  is  noisy  or  sighing,  and  the  shoulders  may  be  slightly 
raised  at  each  inspiration.  Sometimes  a  change  in  the  position 
increases  or  diminishes  the  difficulty  by  modifying  the  pressure  upon 
the  cord.  A  noticeable  slowing  of  the  pulse  accompanies  this  defec- 
tive respiration. 

The  local  symptoms  are  usually  few  and  obscure,  often  nothing 
more  than  the  pain  that  is  felt  at  the  seat  of  fracture  and  is  increased 
by  pressure  or  motion.  Sometimes  there  are  positive  objective  signs: 
an  abnormal  projection  or  depression  of  one  or  more  spinous  pro- 
cesses, an  irregularity  on  the  posterior  wall  of  the  pharynx  jiroduced 
by  the  displaced  body  of  a  vertebra,  lateral  displacement  of  one  or 
more  spinous  processes,  irregularity  in  the  line  of  the  transverse  pro- 
cesses, and  possibly  crepitus  or  abnormal  mobility. 

The  position  and  inobility  of  the  head  vary  greatly  in  different 
cases.  In  some  cases  ti)ey  show  nothing  abnormal,  in  others  the  head 
can  be  moved  freely  to  either  side,  but  not  forward  or  l)ackward,  and 
in  others  it  is  held  iirmly  fixed  in  some  one  position  and  any  attempt 
to  change  that  position  causes  pain.  This  rigidity  is  due  not  to  change 
in  the  relations  of  the  articular  surfaces,  but  to  the  involuntary 
spasmodic  contraction  of  the  muscles  which  is  nature's  method  of  pre- 
venting the  infliction  of  pain  by  movement  of  the  parts. 

It  is  to  be  borne  in  mind  that,  as  stated  above,  this  is  the  region  in 
which  traumatic  hsematomyelia  almost  exclusively  occurs,  and  that 
examination  of  the  sensibility  to  heat,  cold,  and  pain  should  be  made 
whenever,  in  connection  with  more  or  less  motor  paralysis,  there  is 
preservation  of  the  touch-sense. 

It  is  apparent  that  the  diagnosis  of  fracture  of  this  region  may  be 
difficult  or  impossible.  The  most  that  can  be  done  in  many  cases  is  to 
recognize  approximately  the  seat  of  the  injury.  Thus,  paralysis  or 
symptoms  of  irritation  in  the  arms,  even  if  they  first  appear  after 
some  delay,  indicate  a  lesion  above  the  second  dorsal  vertebra,  although 
in  a  few  exceptional  cases  this  symptom  has  existed  wlien  the  injury 
was  lower  on  tlic  spine,  and  was  then  due  pr()bal)ly  to  an  associated 
brain  lesion  or  a  large  collection  of  blood  within  the  spinal  canal.  If 
all  local  and  functional  signs  are  absent  the  diagnosis  is,  of  course, 
impossible,  and  the  real  nature  of  the  injury   may  be  entirely  over- 


172  FRACTURES. 

looked   until   the   pros^ress  of  the   iuflammatiou  or   a  chance  displace- 
ment of  the  fragments  brings  it  to  light. 

The  prognosis  is  extremely  unfavorable.  Gurlt's  tables  contain  96 
fatal  cases,  and  only  8  which  ended  in  recovery,  and  in  one  of  these 
the  symptoms  reappeared  after  a  fall  and  the  patient  died  in  conse- 
quence. In  one-third  of  the  cases  death  took  place  within  the  first 
four  days;  in  20  between  the  iifth  and  twelfth;  in  11  between  the 
thirteenth  and  thirty-sixth  ;  and  in  one  case  the  patient  survived  five 
months.  I  have  known  two  cases  in  which  life  was  prolonged  more 
than  a  year,  without  change  in  the  paralysis.  In  h^ematomyelia  the 
prognosis  is  much  more  favorable. 

Fractures  of  the  Lower  Ten  Dorsal  and  First  Two  Lumbar  Vertebrae. 

This  region  includes  another  point  at  which  fractures  are  very 
common,  the  lower  dorsal  and  the  first  lumbar  vertebrae.  Its  position 
below  the  origin  of  the  brachial  plexus  excludes  the  involvement  of 
the  arms  in  the  paralysis  except  in  rare  cases  where  this  unusual  exten- 
sion is  due  apparently  to  the  spread  of  inflammatory  softening  of  the 
cord  or  to  the  pressure  of  extravasated  blood.  Paralysis  of  the  lower 
limbs,  the  bladder,  and  rectum,  which  is  one  of  the  common  results  of 
fracture  in  this  division  as  well  as  in  the  higher  ones,  may  be  entirely 
absent  at  the  beginning,  especially  after  fracture  of  the  second  lumbar 
vertebra,  or,  more  frequently,  may  be  incomplete,  the  motor  paralysis 
being,  as  a  rule,  more  marked  than  the  paralysis  of  sensation.  The 
latter  may  extend  as  high  as  the  lower  part  of  the  breast,  or  may  stop 
at  the  groin,  and  sometimes  even  does  not  reach  above  the  lower  part 
of  the  thigh.  A  common  result  of  the  paralysis  is  the  immediate 
retention  of  urine  and  feces,  followed,  as  before  mentioned,  by  incon- 
tinence and  by  alkaline  decomposition  of  the  urine  and  cystitis.  This 
incontinence  persists  until  death  takes  place  or  improvement  begins. 
The  disturbance  in  the  function  of  the  bowels  aided  by  the  flaccidity 
of  the  abdominal  muscles  produces  tympanites,  which  makes  its 
appearance  usually  within  a  day  or  two  and  may  be  sufficiently  marked 
to  interfere  with  respiration  by  crowding  the  diaphragm  upward  and 
opposing  its  contraction.  In  other  cases,  even  of  apparently  severe 
injury  to  the  body  of  a  vertebra,  there  may  be  an  entire  absence  of 
paralvtic  symptoms  and  even  of  those  of  meningeal  irritation. 

The  diagnosis  is  aided  by  objective  symptoms,  which  are  more 
marked  and  distinctive  than  those  found  after  fractures  of  the  upper 
portion  of  the  column,  because  as  the  fracture  in  the  great  majority  of 
the  cases  involves  the  body  of  the  vertebra,  and  is  comminuted  or 
accompanied  by  displacement,  there  is  usually  a  recognizable  deformity 
consisting  in  an  angular  change  in  the  long  axis  of  the  spine,  with 
projection  of  the  spinous  process  of  the  broken  vertebra  or  of  the  one 
immediately  above  it.  This  change  in  the  position  of  the  spinous 
process  is  sometimes  so  marked  that  the  finger  can  be  pressed  deeply 
in  between  it  and  the  next  lower  one. 

The  possibility  of  traumatic  hsematomyelia  in  the  lower  part  of  this 
region  must  not  be  overlooked. 


FRACTURES  OF  THE   VERTEBRM  173 

The  prognosis,  as  regards  both  life  and  recovery  of  function,  is  more 
favorable  than  after  fracture  at  a  higher  point. 

Fractures  of  the  Lower  Three  Lumbar  Vertebrae. 

Fractures  of  this  portion  of  the  spine  appear  to  be  exceedingly- 
rare.^  The  absence  of  paralytic  symptoms  and  recognizable  displace- 
ment would  make  the  diagnosis  during  life  practically  impossible. 

As  this  portion  of  the  spinal  canal  contains  only  nerve  trunks,  which 
are  better  fitted  by  their  texture  and  comparative  independence  of  each 
other  to  resist  or  escape  damaging  pressure  by  displaced  fragments  than 
the  spinal  cord  itself  is,  paralysis  may  be  absent  even  wlien  the  dis- 
placement is  marked  ;  in  some  cases  it  has  been  complete,  both  of 
motion  and  sensation,  over  the  limbs  and  abdomen.  The  patient  may, 
however,  be  unable  to  walk  in  consequence  of  the  loss  of  support  occa- 
sioned by  the  fracture,  or  he  may  ^\'alk  only  feebly  and  in  a  bent  pos- 
ture. But  if  union  takes  place,  even  if  the  deformity  persists,  he  may 
be  as  strong  and  capable  as  before.  In  short,  the  prognosis  is  favor- 
able as  regards  both  life  and  function. 

Course  and  Terminations. 

The  course  and  terminations  of  fracture  of  the  spine,  with  their 
many  variations  as  regards  both  the  life  and  principal  functions  of 
the  patient,  have  been  indicated  in  the  preceding  section  ;  we  have 
now  to  consider  the  changes  effected  in  the  broken  bone  by  the  process 
of  repair,  and  to  describe  some  of  the  later  symptoms  with  more 
detail. 

Repair  takes  place  by  a  callus  which  may  remain  fibrous,  but  is 
usually  bony  and  possesses  ample  solidity  notwithstanding  the  com- 
mon persistence  of  displacement.  In  fractures  that  have  been  healed  for 
a  long  time  is  found  the  same  absorption  of  projecting  angles  and  sur- 
faces which  has  been  noticed  in  connection  with  other  fractures,  and 
this  absorption  is  especially  marked  in  the  bodies  of  the  vertebrae. 
If  several  adjoining  vertebrae  are  broken  at  the  same  time  the  inter- 
vertebral disks  disappear  in  part  by  absorption,  and  the  remaining 
portions  undergo  partial  or  complete  ossification,  uniting  structurally 
with  the  vertebrae,  and  thus  forming  a  more  or  less  extensive,  rigid, 
bony  mass.  The  length  of  time  required  for  consolidation  appears  to 
be  greater  than  for  that  of  other  spongy  bones. 

A  number  of  instances  of  complete  pseudarthrosis  have  been  re- 
corded and  their  origin  differently  interpreted.  Gurlt  collected  21  such 
cases  :  1  of  the  odontoid  process,  4  of  the  spinous  processes  of  the 
cervical,  dorsal,  and  lumbar  vertebrae,  and  of  the  sacrum,  3  of  the 
transverse  processes  of  lumbar  vertebrae,  11  of  the  arches  of  lumbar 
vertebrae,  and  2  of  the  side  of  the  upper  false  vertebra  of  the  sacrum. 
Meckel  considered  the  11  cases  involving  the  arches  of  lumbar  ver- 

1  If  the  specimens  of  supposed  ununited  fractures  of  the  arch  of  these  bones,  which  have 
been  found  upon  the  dissecting-table,  in  museums,  and  in  old  Indian  graves,  are  accejited 
as  such,  they  raise  the  rjuestion  whether  similar  fractures  are  not  more  common  than  has 
been  supposed,  and  whether  they  may  not  be  present,  without  displacement,  in  some  of 
the  severe,  so-called  strains  of  this  region.    The  x-rays  may  answer  it. 


174  FRACTURES. 

tebrse  as  instances  of  arrest  of  development,  comparing  them  with  the 
vertebrae  of  some  reptiles,  which  consist  normally  of  a  separate  body 
and  arch,  and  in  which  many  of  the  processes  also  remain  ununited. 
Otto  opposed  this  view,  because  the  position  of  the  false  joint  does  not 
correspond  to  that  of  the  line  between  the  diaphysis  and  epiphysis,  and 
Wyman,^  who  reported  eleven  additional  cases  and  did  not  know  of 
these  earlier  ones,  held  the  same  opinion  for  the  same  reason.  Gurlt 
accepted  Meckel's  opinion  concerning  the  arches  of  the  lumbar  verte- 
brae, and  claims  that  it  is  probably  true  also  of  the  other  cases.  His 
reasons  are  that  there  is  no  trace  of  injury  to  other  parts,  and  that  it 
is  known  that  fracture  limited  to  a  vertebral  arch,  a  spinous,  or  a  trans- 
verse process  is  exceedingly  rare ;  that  most  of  the  cases  relate  to  the 
lowest  lumbar  vertebrae,  fractures  of  which,  of  any  kind,  are  rare,  and 
in  the  case  of  the  fifth  unknown  ;  and  that  the  identity  of  the  position 
of  the  joint  in  all  corresponding  cases,  and  its  perfect  structure,  point 
strongly  to  an  arrest  of  development,  and  are  incompatible  with  a  frac- 
ture by  external  violence.  Shepherd  ^  reports  another  of  the  fifth 
lumbar  vertebra  found  in  the  dissecting-room. 

Suppuration  at  the  seat  of  fracture,  which  is  very  rare  in  other  bones, 
seems  to  be  more  common  after  simple  fracture  of  the  spine,  and  is 
attributed  by  Gurlt  to  the  greater  complexity  of  the  anatomical  condi- 
tions and  to  the  less  perfect  immobility  maintained  during  the  progress 
of  the  case.  His  statistics  contain  eight  cases  in  which,  excluding 
instances  of  suppurative  meningitis,  more  or  less  pus  was  found  after 
death  at  the  seat  of  fracture. 

As  to  the  recovery  of  the  cord  after  injury,  with  restoration  of  func- 
tion, nothing  definite  is  known  beyond  the  fact  that  a  number  of  autop- 
sies made  at  various  periods  after  injury  have  shown  the  cord  more  or 
less  completely  divided,  or  reduced  to  pulp  at  the  compressed  part,  or 
replaced  by  fibrous  tissue.  There  is  nothing  to  prove  that  a  disinte- 
grated portion  can  be  restored,  or  that  divided  cords  can  be  reunited, 
and  it  is  not  easy  to  see  how  proof  of  such  a  fact  could  be  furnished 
except  by  experiment.  In  those  cases  in  which  paralysis  has  disap- 
peared after  a  time,  it  is  impossible  to  know  exactly  what  was  the 
nature  of  the  lesion  of  the  cord  that  caused  it,  but  probably  most  of 
them  are  cases  of  moderate  heematomyelia. 

In  one  or  two  cases  recently  published,  in  which  a  partial  division 
of  the  cord  has  been  demonstrated  by  operation,  partial  recovery  of 
function  has  followed.  I  doubt  if  this  can  be  held  to  prove  more  than 
that  nerve-fibres  of  the  cord  can  reunite,  with  re-establishment  of 
conduction.  That  destruction  of  the  gray  matter  can  be  made  good 
must  still  be  deemed  unproved,  and  unfortunately  that  destruction  is 
the  common  lesion  in  fracture. 

The  troubles  created  by  paralysis  of  the  bladder  are  very  serious, 
and  often  hasten  a  fatal  termination.  They  begin,  usually  promptly, 
with  retention,  which  if  not  looked  for  by  the  surgeon  may  pass  unno- 
ticed, since  it  gives  the  patient  no  pain,  until  the  distention  of  the 
bladder  has  become  so  great  that  the  urine  begins  to  dribble  away 

1  Wyman  :  Boston  Medical  and  Surgical  Journal,  August  14,  1869. 

2  Shepherd  :  Montreal  Medical  Journal,  June,  1892. 


FRACTURES   OF  THK    VERTEBRM  175 

through  the  urethra.  The  symptoms  and  usual  ajusequeuccs  of  the 
consequent  cystitis  are  such  as  are  commonly  olxserved  when  the  same 
affection  is  excited  by  other  causes,  and  do  not  require  a  detailed  de- 
scription here  ;  but  in  addition  to  these  common  ones  there  are  occa- 
sionally observed  others  of  great  gravity,  such  as  sloughing  of  the  wall 
of  the  bladder,  and  pericystitis  with  formation  of  abscesses. 

Every  effort  should  be  made  to  delay  the  appearance  of  this  compli- 
cation and  to  diminish  its  severity,  and  with  this  oljject  the  water  must 
be  regularly  drawn  as  soon  as  the  first  signs  of  retention  appear.  It 
is  usually  sufficient  to  use  the  catheter  twice  a  day  ;  it  must  Ije  steril- 
ized and  passed  witli  even  more  tlian  tlie  usual  precautions  and  gentle- 
ness because  the  patient's  insensitiveness  creates  an  additional  risk  of 
doing  damage  unwittingly  to  the  urethral  wall.  After  cystitis  has 
appeared  and  the  urine  has  become  turbid,  the  bladder  should  be 
washed  once  or  twice  a  day.  Permanent  drainage  of  the  l)ladder 
through  a  perineal  or  suprapubic  incision  has  been  employed  with 
advantage. 

Bed-sores  appear  promptly  after  any  fracture  tliat  has  caused  para- 
plegia by  a  complete  transverse  lesion  of  the  cord,  but  are  absent  in 
heematomyelia.  The  skin  at  first  becomes  white,  then  mottled,  and 
then  sloughs,  and  the  slough  spreads  peripherally  and  in  depth.  The 
commonest  seat  is  the  skin  covering  the  convexity  of  the  sacrum,  then 
other  prominent  points  upon  the  back  and  legs.  The  (;ause  of  this 
early  sloughing  has  been  thought  to  lie  in  injury  to  nerves  or  nerve 
centres  presiding  over  the  nutrititjn  of  the  parts;  but  Mr.  Shaw^ 
explains  it  by  the  pressure  which  is  continued  for  a  length  of  time 
and  with  an  absence  of  interruption  unknown  except  in  connec- 
tion with  paralysis.  Not  only  is  the  patient  unaljle  to  move,  but  he  is 
insensitive  to  the  prolonged  jiressure,  and  does  not  seek  to  change  his 
position  or  to  have  it  changed.  He  lies  absolutely  motionless  in  one 
settled  position ;  the  pressure  interrupts  the  circulation  at  certain 
points,  and,  if  this  interruption  continues  unrelieved,  the  part  dies, 
riie  presence  of  urine  or  liquid  feces  may  prove  an  additional  source 
of  irritation,  as  may  also  creases  or  irregularities  in  the  bed-clotliing, 
and  lack  of  attention  and  scrupulous  cleanliness.  The  rapid  improve- 
ment which  sometimes  takes  })lace  in  these  sloughs,  even  when  the 
paralysis  remains  complete,  as  soon  as  the  consolidation  of  the  fracture 
is  sufficiently  advanced  to  allow  the  patient  to  be  readily  moved,  is 
corroboration  of  the  opinion.  Some  cases  which  have  recovered  with 
pf.'rinanent  para|)legia  have  shown,  on  the  other  hand,  a  very  marked 
tendency  to  the  formation  of  sloughs  on  slight  provocation,  and  in  one 
case^  the  tarsal  bones  of  both  feet  became  necrotic. 

In  those  cases  in  which  the  patients  survive  the  injury  and  its  more 
immediate  consequences,  it  is  sometimes  found  that  the  paralysis  grad- 
ually diminishes  and  may  even  disappear  entirely.  The  beginning  of 
the  improvement  is  sometimes  marked  by  the  appearance  of  sharp 
darting  pains  in  the  limbs  and  of  muscular  twitchings  excited  by  slight 
causes,  such  as  pinching  or  touching  the  skin  ;  then  the  power  of  vol- 

'Shaw  :  Holmes's  System  of  Surgery,  Am.  ed.,  vol.  i.  p.  810. 
*  Courier  Medical,  November  11,  1882. 


176  FEACTUBES. 

untary  motion  returns,  first  in  one  muscle,  then  in  another.  Sensation 
returns  usually  before  motion  ;  the  bladder  is  found  to  be  again  able  to 
retain  a  certain  quantity  of  urine  and  to  expel  it  with  some  force;  and 
a  similar  improvement  is  presented  by  the  rectum,  althougli,  as  a  rule, 
even  in  the  best  cases,  the  functions  of  the  rectum  and  bladder  remain 
partially  and  permanently  disabled.  The  improvement  in  the  paralysis 
may  be  very  slight,  or  it  may  go  on  to  complete  restoration  of  function, 
or  it  may  be  arrested  at  any  intermediate  stage.  Cases  have  been 
referred  to  in  which  a  permanent  deformity  existed,  but  the  functions 
of  the  body  and  limbs  were  in  no  manner  disturbed  by  it.  Finally, 
after  a  short  period  of  apparent  recovery,  symptoms  of  progressive 
degeneration  of  the  cord  or  of  pachymeningitis  may  appear. 

Treatment. 

The  indications,  as  in  other  fractures,  are  to  reduce  displacement 
and  to  immobilize  until  repair  shall  have  taken  place,  but  the  limita- 
tions which  exist  in  so  many  other  fractures  exist  here  to  an  even 
greater  extent  because  of  the  uncertainty  as  to  the  character  of  the 
displacement,  the  difficulty  in  modifying  it  as  desired,  and  the  fre- 
quent association  of  dominant  lesions  of  the  cord  which  cannot  possibly 
be  remedied.  The  condition  of  the  cord,  as  indicated  by  the  symp- 
toms, should  usually  determine  the  measure  of  benefit  to  be  expected 
from  treatment,  but  unfortunately  we  cannot  distinguish  with  certainty 
between  a  complete  division  or  crush  of  the  cord  which  cannot  be 
repaired  and  compression  by  bone  or  extravasated  blood  which  will  be 
recov^ered  from  if  the  pressure  is  relieved.  We  know  that  in  the  great 
majority  of  cases,  a  majority  which  is  greater  the  higher  the  injury  is 
situated  in  the  vertebral  column,  the  condition  of  the  cord  is  hopeless 
or  at  the  most  can  only  be  mitigated. 

In  the  first  care  of  the  patient — transport,  undressing,  examination 
— he  must  be  handled  with  constant  watchfulness  to  avoid  producing 
or  increasing  displacement.  Then,  if  the  fracture  is  of  a  spinous  pro- 
cess alone  or  of  the  column  without  recognizable  displacement  and 
without  symptoms  of  injury  of  the  cord,  confinement  to  the  bed,  pref- 
erably aided  by  a  plaster-of-Paris  corset,  is  all  that  is  required. 

If  there  is  recognizable  displacement — gibbosity  of  the  spine — with- 
out cord  symptoms  immobilization  in  the  plaster  corset  is  indicated, 
with  or  without  an  attempt  to  correct  the  displacement. 

If  symptoms  of  pressure  on  or  injury  of  the  cord  coexist  an  attempt 
should  be  made  to  relieve  the  condition  by  correcting  the  displacement. 

The  means  of  accomplishing  this  are  traction  upon  the  trunk  to 
straighten  it  by  elongation,  direct  pressure  forward  upon  the  project- 
ing angle,  and  open  operation. 

When  the  injury  is  in  the  cervical  or  upper  dorsal  region  traction 
can  be  made  by  turning  the  patient  upon  his  side  and  pulling  by  the 
chin  and  occiput;  and  by  gradually  changing  the  direction  of  the 
traction  by  moving  the  head  backward  while  pressure  is  made  against 
the  spine  below  the  fracture  the  angular  displacement  can  sometimes 
be  completely  corrected.     But  when  the  injury  is  at  a  lower  point,  and 


FRACTURES  OF  THE   VERTEBRA. 


177 


especially  if  the  patient  is  large  aud  heavy,  traction  thus  made  is  not 
sutlficient  even  with  the  aid  of  anaesthesia ;  and  even  pressure  with  the 
knee  or  hand  against  the  angle  (the  patient  being  on  his  side)  wliile 
the  hips  and  shoulders  are  pressed  backward  may  fail  to  make  any 
change  in  the  condition. 

Suspension  by  the  apparatus  used  in  disease  of  the  spine  has  been 
employed  by  some  with  advantage,  but  I  have  not  ventured  to  try  it. 

Fig.  83. 


Fracture  of  spine.    Correction  of  the  displacement  by  suspension  and  plaster  jacket. 


Instead,  I  have  used  a  long  plank,  placing  the  patient  upon  it,  secur- 
ing his  shoulders  to  one  end,  and  then  gradually  raising  that  end  so 
that  the  lower  limbs  w^ould  make  the  desired  traction  by  their  weiglit. 
AVhile  the  patient  is  thus  supported  pressure  forward  upon  the  angle 
can  be  made  by  a  bandage  or  stick  ])assed  between  it  and  the  jilank. 
If  the  materials  for  a  plaster  corset  have  been  previously  ])re])ared,  in 
the  form  of  bi'oad  strips  of  muslin  or  canton-flannel  soaked  iu  jilaster 
cream,  and  placed  at  the  proper  point  upon  the  plank  before  the 
patient  has  been  laid  upon  it,  the  dressing  can  be  easily  and  rapidly 


178  FRACTURES. 

completed  while  the  patient  remains  suspended  by  bringing  forward 
the  ends  of  the  strips  around  the  body  on  each  side. 

Dandridge  recommends  horizontal  suspension  on  a  narrow  strip  of 
stout  muslin,  like  a  hammock,  which  is  then  included  in  the  plaster 
jacket.  The  method  is  praised  by  those  who  have  employed  it  in 
Pott's  disease  of  the  spine.  Or  partial  suspension  can  be  made  by  a 
bandage  resting  against  the  angle  of  the  gibbosity  (Fig.  83). 

In  a  few  cases  an  existing  paraplegia  has  immediately  disappeared 
during  suspension,  and  although  in  others  the  symptoms  have  been 
temporarily  aggravated  I  think  we  are  justified  in  deeming  the  method 
safe  and  probably  efficient  to  correct  an  angular  displacement  due  to 
fracture  or  crushing  of  the  body  of  a  vertebra  or  of  the  pedicles  or 
articular  processes  and  also,  though  less  certainly,  a  forward  displace- 
ment of  one  segment.  It  cannot  correct  the  much  less  common  dis- 
placement forward  into  the  canal  of  the  posterior  portion  of  the  ver- 
tebral arch,  the  spinous  process  with  one  or  both  laminae,  or  probably 
a  fracture-dislocation  in  which  one  or  both  inferior  articular  processes 
of  an  upper  vertebra  have  lodged  in  front  of  the  corresponding  supe- 
rior processes  of  the  next  lower  one. 

In  reduction  by  open  operation  a  longitudinal  incision  is  made  along 
the  median  line  with  its  centre  at  the  apex  of  the  angle  of  the  frac- 
ture, and  the  soft  parts  separated  on  each  side  from  the  spinous  process 
and  laminae  of  the  vertebra  forming  the  upper  part  of  the  angle,  cut- 
ting through  both  laminae,  if  unbroken,  and  removing  them  with  the 
spinous  process.  If  indicated  the  opening  in  the  spinal  canal  is 
enlarged  upward  or  downward  by  removal  of  the  adjoining  spinous 
process  and  laminae,  and  the  displacement  of  the  body  of  the  vertebra 
is  corrected  by  manipulation  guided  by  the  eye  and  perhaps  aided  by 
traction  with  a  blunt  hook  passed  into  the  spinal  canal.  Hemorrhage 
beneath  the  dura  is  relieved  by  evacuation  through  an  incision. 

A  large  number  of  cases  have  been  thus  operated  upon  during  the 
last  few  years,  and  with  marked  benefit  in  some.  It  is  admitted  by  all 
that  the  operation  can  do  good  in  only  a  small  proportion  of  cases, 
and  it  is  probable  even  that  that  proportion  is  less  than  is  indicated  by 
the  statistics  because  it  is  not  clear  that  the  improvement  which  has 
sometimes  followed  was  the  result  of  the  operation;  similar  improve- 
ment has  been  noted  in  apparently  identical  cases  not  operated  upon, 
some  of  them  probably  cases  of  haematomyelia.  It  must  also  be 
admitted,  I  think,  that  the  operation  is  not  likely  to  do  harm  and  that 
occasionally  it  discloses  an  important  condition  which  could  not  other- 
wise be  recognized  and  corrected.  My  own  inclination  is  strongly 
toward  reliance  upon  traction  and  the  plaster  jacket,  systematic  use  of 
which  might  show  a  gain  as  great  as  that  which  BurrelP  found  in  the 
Boston  City  Hospital:  33  per  cent,  of  recoveries  as  against  22  per 
cent,  under  expectant  treatment.  I  believe,  for  reasons  above  given, 
that  in  the  common  form  of  injury  with  angular  displacement — gib- 
bosity— reduction  can  almost  always  be  accomplished  as  well  in  this 

1  Burrell:  Annals  of  Surgery,  February,  1895. 


FRACTURES  OF   THE   VERTEBRA.  179 

way  as  by  operation,  and  that  the  latter  may  find  its  special  indica- 
tions in  cases  of  intraspinal  hemorrhage  and  those  rare  ones  in  whicli 
the  posterior  portion  of  the  arch  is  driven  into  the  canal  and  presses 
upon  the  cord.  Thorbnrn/  after  a  personal  experience  of  seven  eases 
of  operation  and  study  of  about  200  published  eases,  says  he  has 
found  no  clear  evidence  of  benefit  from  it.  Nevertheless,  he  deems 
laminectomy  justifiable  "  (1)  in  compound  fracture;  (2)  in  injuries  of 
the  laminje  and  spinous  processes  with  lesion  of  the  cord  when  the 
crush  is  probably  incomplete;  (3)  when  the  symptoms  are  mainly  or 
entirely  due  to  thecal  or  perithecal  hemorrhage;  (4)  in  pachymenin- 
gitis or  peripachymeningitis,  which  may  follow  an  injury  after  a  very 
long  period ;  and  (5)  in  cases  of  compression  of  the  cauda  equina." 

Of  the  great  value  of  the  plaster  jacket,  applied  during  suspension, 
in  aiding  consolidation  of  the  fracture  in  cases  in  which  the  disability 
is  due  to  the  fracture  rather  than  to  injury  of  the  cord,  there  can  be  no 
question.^ 

The  general  treatment,  when  paraplegia  is  present,  is  to  place  the 
patient  upon  a  water-bed,  carefully  prevent  irritation  of  the  skin  by 
moisture  or  creases  in  the  sheets,  and  regularly  empty  the  bladder  and 
bowels.     Later  in  the  case  electricity  may  render  some  service. 

iThorburn:  Lancet,  August  11,  1894. 

^See  Papail,  De  I'emloi  du  corset  pl4tre  dans  les    lesions  de    la   colonue  vertebral^*., 
Paris,   1887. 


CHAPTER  XII. 

FRACTURES  OF  THE  BONES  OF  THE  FACE. 
1.  Fractures  of  the  Nose. 

Under  this  term  we  include  not  only  the  two  nasal  bones,  but  also 
those  upon  which  they  rest,  the  septum,  the  nasal  process  of  the  supe- 
rior maxillary,  and  the  nasal  spine  of  the  frontal.  The  fracture  may 
involve  one  or  both  nasal  bones  or  adjoining  processes  ;  it  may  be  simple 
or  compound,  multiple  or  comminuted ;  and  it  may  be  associated  with 
other  fractures  of  neighboring  bones,  the  most  important  of  which  is 
fracture  of  the  cribriform  plate  of  the  ethmoid.  In  the  great  majority 
of  cases  the  fracture  is  a  more  or  less  comminuted  one,  occupying  the 
lower  half  of  the  nasal  bones,  the  main  line  of  fracture  running  trans- 
versely or  obliquely,  and  the  fragments  are  displaced  backward  or  back- 
ward and  to  one  side,  according  to  the  direction  of  the  force  that  has 
produced  the  injury.  In  rare  cases  the  fracture  involves  only  one 
nasal  bone,  or  there  may  be  dislocation  of  one  or  both  bones.  The 
cartilages  which  form  the  alee  may  be  broken  or  torn  from  their  attach- 
ments to  the  bone,  and  that  which  forms  the  septum  is  frequently 
broken  in  connection  with  fractures  of  the  bones  themselves,  or  sepa- 
rated from  the  vomer. 

The  symptoms  by  which  fracture  may  be  recognized  are  deformity, 
mobility,  and  crepitus.  If  the  nose  is  grasped  by  the  thumb  and  finger 
lateral  mobility  with  crepitus  can  usually  be  recognized,  and  displace- 
ments may  at  the  same  time  be  appreciated.  The  separation  or  fracture 
of  the  septum  is  recognized  by  exploration  within  the  nostrils.  The 
swelling  of  the  soft  parts,  which  appears  promptly,  will  mask  any  but 
an  extreme  displacement. 

Other  symptoms  which  may  be  present,  but  which  are  by  no  means 
pathognomonic,  are  free  bleeding  from  the  nose,  and  occasionally 
emphysema  of  the  eyelids  and  face.  Bleeding  is  often  severe  and 
sometimes  recurrent  and  difficult  to  arrest,  but  rarely  endangers  life. 
Emphysema  generally  has  its  origin  in  an  effort  of  the  patient  to  blow 
his  nose  ;  the  air  is  forced  into  the  subcutaneous  cellular  tissue  through 
a  rent  in  the  mucous  membrane  and  spreads  promptly  to  the  eyelids 
and  sometimes  over  the  rest  of  the  face. 

An  occasional  symptom,  when  the  fracture  has  extended  into  the 
adjoining  portion  of  the  superior  maxillary  bone,  is  obstruction  to  the 
flow  through  the  lachrymal  duct  in  consequence  of  its  inclusion  in  the 
line  of  fracture.  Another  and  more  common  one  is  the  difficulty  or 
impossibility  of  breathing  through  the  nose,  the  result  of  inflammatory 
swelling  of  the  mucous  membrane;  and,  finally,  in  the  comminuted 
fractures  that  are  or  have  become  compound,  suppuration  may  be 
(  ISO  ) 


FRACTURES  OF  THE  BOXES  OF  THE  FACE.  181 

maintained  for  weeks  or  months  until  all  the  necrosed  frao;mcnts  have 
worked  their  way  out  or  have  been  removed.  It  occasionally  happens, 
too,  that  a  tendency  is  manifested  toward  inflannnatory  complications 
in  the  neighborliood,  abscesses  form  in  and  about  the  nose,  portions  of 
bone  or  cartilage  become  necrosed  and  are  exfoliated,  and  a  constant 
purulent  discharge  from  the  nostrils  is  maintained. 

It  is  so  important  that  displacement  should  be  corrected  that  an 
ana?sthetic  should  be  used  if  a  thorough  exploration  cannot  be  made 
without  its  aid,  and  the  surgeon  should  spare  no  pains  to  satisfy  liim- 
self  as  to  the  condition  and  position  of  the  bones.  The  examination 
cannot  prudently  be  long  postponed,  for  the  bones  of  the  face  unite 
promptly,  and  more  than  once  it  has  been  found  impossible  to  correct 
a  displacement  after  eight  or  ten  days  had  elapsed  ;  firm  union  may  be 
expected  within  a  fortnight  or  three  weeks. 

The  prognosis  as  regards  life  is  favorable,  except  in  those  cases  in 
which  the  skull  is  at  the  same  time  broken,  and  in  those  few  others  in 
which  recurrent  hemorrhages,  of  which  no  satisfactory  explanation  is 
given,  show  themselves.  But  as  regards  the  avoidance  of  deformity 
the  outlook  is  not  so  favorable,  because  it  is  not  always  easy  to  recog- 
nize or  correct  a  displacement  through  the  swollen  tissues  and  the 
persistence  of  even  a  slight  one  is  likely  to  be  a  noticeable  blemish. 

The  treatment  consists  mainly  in  the  reduction  of  the  displacement, 
for  it  is  seldom  possible  to  apply  any  apparatus  or  dressing  that  will 
prevent  a  recurrence  of  tlie  displacement  if  there  is  any  tendency 
toward  it.  The  reduction  when  there  is  depression  is  accomplished  by 
pressure  made  from  within  the  nostril,  upon  the  septum,  if  broken  or 
displaced,  as  well  as  upon  the  bones,  aided  by  manipulation  or  model- 
ling of  the  fragments  on  the  outside.  The  interval  between  the  septum 
and  the  side  of  the  nose  at  the  part  of  the  nostril  corresponding  to 
the  nasal  bone  is  so  small  that  a  strong  flat  instrument,  such  as  a  perios- 
teum elevator,  must  be  used,  one  that  is  small  enough  to  work  within 
the  narrow  space  next  the  nasal  bone,  and  strong  enough  to  transmit 
considerable  pressure.  The  fingers  of  the  left  hand  placed  upon  the 
nose  serve  to  guide  the  instrument  and  to  recognize  the  degree  of  reduc- 
tion that  has  been  obtained.  Cocaine  may  be  used  to  diminish  the  sen- 
sitiveness of  the  mucosa.  Ordinarily  there  is  but  little  tendency  to 
recurrence  of  the  displacement,  except  when  the  fracture  is  comminuted 
and  the  septum  badly  broken  ;  the  only  forces  that  tend  to  change  the 
position  of  the  fragments  are  the  swelling  of  the  external  soft  parts 
and  the  pressure  of  the  air  when  the  patient  seeks  to  clear  his  nose  by 
snuffing  or  blowing. 

The  idea  of  supporting  the  fragments  by  pressure  from  within  the 
nostrils  suggests  itself  so  readily  that  it  is  not  surprising  to  find  recorded 
many  instances  and  several  varieties  in  the  methods  of  its  use.  The 
siuiplest  one  consists  of  packing  the  lower,  and  perhaps  the  middle, 
meatus  on  the  side  toward  which  the  septum  is  displaced  with  strips  of 
iodoform  gauze  for  a  few  days,  so  as  to  hold  the  septum  in  place  and 
thus  support  the  nasal  bones.  This  is  the  method  which  we  have  used 
for  several  years  at  the  Hudson  Street  Hospital.  The  more  elaborate 
ones  are  arrangements  of  rods  supported   by  straps  crossing  the  u])p('r 


182  FRACTURES. 

lip,  and  capable  of  adjustment  in  length  and  direction  within  the  nos- 
tril so  as  to  hold  the  fragments  in  place ;  they  are  said  to  have  been 
efficient  in  some  difficult  cases. 

The  use  of  plaster  or  gutta-percha  splints  moulded  upon  the  outside 
seems  to  me  to  be  entirely  illusory  ;  if  swelling  takes  place  under  them 
it  will  tend  to  reproduce  the  displacement  by  pressure,  if  it  is  present 
when  the  mould  is  applied  its  subsidence  soon  creates  a  gap  between 
the  splint  and  the  skin.  The  best  plan  appears  to  be  repetition  of  the 
reduction  as  often  as  the  displacement  recurs.  Occasionally  the  bridge 
has  been  held  up  by  transfixion  with  a  pin  which  rests  upon  the  solid 
bone  on  each  side.  Recurrence  of  a  lateral  displacement  may  be 
opposed  by  a  pad  of  gauze  secured  against  the  side  of  the  nose  by  a 
strip  of  adhesive  plaster  crossing  both  cheeks. 

Separation  of  the  cartilaginous  septum  from  the  vomer  can  be  treated 
with  a  pair  of  forceps,  one  branch  of  which  is  passed  into  each  nostril, 
lapping  and  grasping  the  bone  and  cartilage  so  as  to  hold  them  in  line. 
The  depression  of  the  bridge,  the  "  saddle  nose,"  which  so  often  is  seen 
after  this  fracture,  constitutes  so  marked  a  disfigurement  that  many 
attempts  have  been  made  to  correct  it.  Operations  upon  the  bone, 
designed  to  detach  and  raise  the  bridge,  have,  as  a  rule,  failed  so  com- 
pletely that  I  was  led  to  try  to  meet  the  indication  by  introducing  a 
suitably  shaped  foreign  body  between  the  skin  and  the  bone.  It  proved 
entirely  successful  in  restoring  the  profile,  and  the  pieces  of  aluminum 
and  gutta-percha  have  remained  in  place  for  several  years  without 
causing  irritation.  [Annals  of  Surgen/,  June,  1896.)  Of  late,  sub- 
cutaneous injection  of  warm  paraffin  has  proved  very  satisfactory. 

2.  Fractures  of  the  Malar  Bone  and  Zygoma. 

Isolated  fractures  of  this  bone  are  rare,  and,  so  far  as  can  be  inferred 
from  the  small  number  of  cases  in  which  a  direct  examination  has  been 
possible,  single  fractures  are  rarer  than  multiple  ones,  and  the  rarest  is 
that  which  is  almost  a  simple  diastasis,  a  separation  at  the  sutures  with 
some  splintering.  Partial  fractures  involving  the  lower  and  outer  por- 
tion of  the  bone  or  the  margin  of  the  orbit  have  been  observed,  and 
also  single  fractures  of  the  frontal  and  zygomatic  processes,  extending 
possibly  into  the  bones  with  which  they  articulate.  In  most  cases  there 
is  depression  of  the  entire  bone  with  fracture  of  the  malar  process  of 
the  superior  maxilla  and  crushing  of  the  anterior  wall  of  the  antrum, 
the  malar  bone  being  displaced  inward  toward  the  antrum  or  sometimes 
backward  into  the  zygomatic  fossa.  The  force  and  direction  of  the 
violence  may  be  such  that  adjoining  portions  of  the  cranium  will  be 
broken,  with  possible  laceration  of  the  brain. 

Fractures  of  the  zygomatic  arch  alone  have  been  caused  by  external 
violence  acting  from  without  inward,  and  in  two  cases  from  within 
outward,  the  patient  having  fallen  forward  upon  a  stick  held  in  the 
mouth.  In  some  of  those  I  have  seen  a  portion  of  the  arch  has  been 
separated  by  two  lines  of  fracture  and  depressed ;  in  one  of  them  one 
of  the  lines  of  fracture  extended  into  the  temporo-maxillary  joint. 
The  displacement  follows  the  direction  of  the  fracturing  force. 


FRACTURES  OF  THE  RONES  OF  THE  FACE. 


183 


The  symptoms  upon  which  the  diaguosis  must  be  made  are  deformity, 
mobility,  and  crepitus.  Unless  tliere  is  much  inflammatory  swelling 
the  deformity,  which  consists  usually  in  a  depression  or  flattening  of  the 
cheek  just  below  the  outer  half  of  the  eye,  can  be  recognized  by  sight 
and  touch,  and  the  irregularity  of  the  line  of  fracture  can  be  readily 
felt  on  the  margin  of  the  orbit,  or,  if  it  extends  to  the  malar  process 
of  the  superior  maxillary  bone,  on  the  under  and  anterior  surface  of 
this  process  by  the  finger  within  the  mouth.  Mobility  and  crepitus 
are  perceived  more  rarely  ;  the  latter  can  be  sometimes  produced  by  the 
movement  of  the  jaw. 

Anaesthesia  or  a  sense  of  formication  in  the  cheek,  nose,  upper  lip, 
and  gum  of  the  corresponding  side  is  sometimes  observed,  and  is  due 

Fig.  84. 


Fracture  of  the  zygoma. 

to  an  extension  of  the  fracture  to  the  infra-orbital  canal  and  tearing  or 
bruising  of  the  superior  maxillary  nerve.  This  symptom  may  be  asso- 
ciated with  the  extravasation  of  blood  in  the  posterior  part  of  tlie  orbit 
sufficient  to  force  the  eye  forward  and  showing  itself  also  under  the 
conjunctiva  and  in  the  eyelids.  Bleeding  from  the  mouth  or  nose  is 
occasionally  seen  as  the  result  of  the  extension  of  the  fracture  through 
the  mucous  membrane  of  the  mouth  or  antrum. 

When  the  fracture  involves  the  zygomatic  arch,  and  the  fragments, 
as  is  usually  the  case,  are  driven  inward,  movement  of  the  jaw  may  be 
difficult  or  impossible,  either  because  the  masseter  has  been  injured,  or 
because  the  depressed  fragments  of  the  arch  are  forced  against  the 
coronoid  process  of  the  inferior  maxilla,  or  into  the  tendon  of  the  tem- 
poral muscle.  In  one  case  the  tip  of  the  coronoid  process  was  broken 
off  by  the  same  blow  that  fractured  the  arch.     The  same  interference 


184  FRACTURES. 

can  be  produced  by  the  displacement  backward  of  the  main  portion  of 
the  bone.  Swelling,  discoloration,  and  pain  are  the  natural  and  con- 
stant results  of  the  fracture  and  the  bruising  of  the  soft  parts. 

The  natural  course  of  these  fractures  is  toward  rapid  repair  without 
excessive  callus,  and  with  gradual  disappearance  of  any  difficulty  that 
may  exist  at  first  in  the  movement  of  the  jaws.  It  is  seldom  possible 
to  reduce  the  displacement  completely,  because,  as  has  been  said,  it  is 
generally  inward,  and  there  is  no  way  of  acting  very  efficiently  upon 
the  bone,  except  through  a  wound  of  the  skin.  The  attempt  must  be 
made  to  move  the  bone  in  the  desired  direction  by  engaging  the  end 
of  the  thumb  or  finger  under  it  in  the  zygomatic  fossa,  introducing  it 
through  the  mouth  if  the  cheek  is  swollen.  It  has  been  proposed,  and 
occasionally  practised,  to  cut  down  upon  the  bone  opposite  the  zygo- 
matic process,  divide  the  fascia  overlying  the  masseter  muscle,  pass  a 
stout  hook  under  the  process,  and  raise  the  bone  by  drawing  upon  it, 
or  to  make  a  smaller  incision  over  the  body  of  the  bone  and  screw  an 
elevator  into  it,  by  which  it  could  then  be  raised. 

Inward  displacement  of  the  zygomatic  arch  cannot  be  directly  acted 
upon  except  by  a  hook  introduced  through  the  skin  or  an  incision.  In 
only  one  of  the  recorded  cases  has  the  displacement  interfered  seriously 
and  for  any  length  of  time  with  the  movement  of  the  jaws  ;  in  this 
one  the  difficulty  increased  steadily  for  some  time  until  the  patient 
could  barely  separate  the  teeth,  and  then  one  morning  while  yawning 
he  felt  something  snap,  and  the  motion  of  the  jaw  at  once  became  and 
remained  free. 

3.  Fractures  of  the  Superior  Maxilla. 

While  the  body  of  this  bone,  protected  as  it  is  by  outlying  processes 
and  other  bones,  is  rarely  fractured,  its  own  processes  are  not  infre- 
quently broken  or  involved  in  the  fractures  of  those  bones  with  which 
they  are  continuous.  Thus,  a  blow  upon  the  nose  breaks  not  only  the 
nasal  bones  but  also  the  nasal  process  of  the  superior  maxilla,  and  a 
blow  upon  the  malar  bone  may  force  in  the  anterior  wall  of  the  antrum 
on  which  it  rests.  The  fractures  are  always  produced  by  direct  vio- 
lence, and  present,  consequently,  considerable  variety  in  their  extent 
and  the  parts  involved,  but  a  fissure  may  extend  to  this  bone  from  a 
fracture  of  the  cranium.  The  alveolar  process  may  be  broken  off  in 
part  or  entirely  by  a  blow  received  on  it  or  on  the  teeth.  A  blow 
received  in  front,  at  or  below  the  level  of  the  nostrils,  may  produce  a 
horizontal  line  of  fracture  separating  the  alveolar  and  palatal  processes 
from  the  body  of  the  bone,  and  including  also  the  pterygoid  plates. 
Falls  from  a  height  have  caused  a  vertical  line  of  fracture  or  diastasis 
between  the  two  bones  along  the  median  line  of  the  mouth,  extending 
even  through  the  soft  palate,  and  associated  with  fracture  of  the  malar 
or  nasal  bones.  In  a  very  few  cases  a  line  of  fracture  on  each  side  at  the 
canine  tooth  has  separated  the  intermediate  portion,  with  marked  dis- 
placement and  mobility.  Fractures  of  the  alveolar  process,  even  with 
much  displacement  and  mobility,  present  but  little  gravity,  for  they 
heal  rapidly  and  without  necrosis  except  of  small  pieces  of  the  sockets 
of  teeth  displaced  at  the  same  time. 


FRACTURES   OF  THE  BONES   OF  THE  FACE.  185 

It  occasionally  happens  that  one  or  both  bones  are  driven  in  with 
multiple  and  comminuted  fracturing  of  them  and  of  the  adjoining 
ones.  The  earliest  known  case  of  the  kind  was  reported  by  Wiseman, 
and  has  been  extensively  quoted.  The  upper  jaw  was  driven  in  so 
far  that  the  finger  could  not  be  introduced  between  the  palate  and  the 
posterior  wall  of  the  pharynx.  Wiseman  inserted  a  blunt  hook  through 
the  mouth  and  easily  drew  the  bone  forward  into  place;  as,  however, 
the  displacement  recurred  very  easily,  he  left  the  hook  behind  the 
palate  and  had  it  drawn  upon  constantly  by  the  patient  or  his  friends 
until  consolidation  had  taken  place.  Quite  a  number  of  similar  cases 
(Gurlt  collected  upward  of  twenty)  have  been  reported,  all  the 
result  of  great  violence,  either  by  falls  from  a  height  or  the  passage 
across  the  face  of  a  heavy  wagon,  or  a  violent  blow.  In  one  of  my  own, 
a  blow  by  a  descending  elevator  upon  an  upturned  face,  the  nasal  bones 
were  separated  from  the  frontal  along  the  suture  line,  the  right  malar 
and  zygoma  broken,  and  b<jtli  superior  maxillse  displaced  downward  and 
backward  and  separated  from  each  other  along  the  median  line  of  the 
hard  palate.  In  one  case  the  bones  of  the  face  were  so  movable  that 
they  moved  up  and  down  when  the  patient  swallowed,  as  if  they  were 
restrained  only  by  the  skin.  In  most  of  them  the  patients  recovered, 
and  it  is  worthy  of  remark  that,  notwithstanding  the  degree  of  the  vio- 
lence and  the  extent  of  the  injury,  it  seldom  happens  that  the  fracture 
involves  the  cranium.  The  reason  lies  apparently  in  the  direction  in 
which  the  fracturing  force  is  applied,  a  direction  outside  of  and  more 
or  less  parallel  to  the  surface  of  the  cranium  and  not  in  the  line  of  one 
of  its  diameters.  The  bones  of  the  face  are,  as  it  were,  torn  off  the 
cranium  rather  than  driven  back  upon  it. 

Very  extensive  mutilation  of  the  face  has  been  caused  by  gunshot 
wounds,  especially  in  attempts  at  suicide  when  the  muzzle  of  the  gun 
has  been  placed  within  the  mouth,  but  it  is  rare  for  ordinary  violence 
to  lead  to  much  loss  of  tissue.  Malgaigne  speaks  of  the  following  case 
as  unique  in  this  respect  in  his  experience  :  A  boy  was  kicked  in  the 
face  by  a  horse  ;  the  superior  maxillary,  nasal,  and  palatal  bones  were 
extensively  comminuted,  and  the  skin  torn  and  bruised.  Recovery 
took  place,  but  with  much  deformity.  The  nasal  bones,  the  anterior 
portion  of  the  alveolar  arch,  and  the  greater  part,  if  not  all,  of  the 
hard  palate  had  disappeared.  There  was  no  longer  either  nose  or 
mouth  ;  the  lips  were  united  by  a  firm  cicatrix,  and  the  mouth  and 
nostrils  were  represented  by  an  oval  opening  between  the  nasal  pro- 
cesses of  the  superior  maxillae.  Through  this  opening  the  patient 
breathed,  spoke,  drank,  and  ate. 

The  diagnosis  of  fracture  is  ordinarily  made  without  any  difficulty, 
since  large  portions  of  the  bone  are  open  to  direct  examination  with 
the  finger  through  the  mouth  and  on  the  cheek.  Irregularity  of  out- 
line, mobility,  displacements,  and  crepitus  can  be  readily  recognized. 
In  some  few  cases  where  there  was  no  displacement  the  diagnosis  has 
been  in  doubt,  and  Guerin^  has  jwinted  out  a  symptom  which  might 
be  useful  under  such  circumstances.  It  has  been  said  that  the  ptery- 
goid apophysis  is  always  l)roken  when  the  line  of  fracture  crosses  the 

1  fJncriii  :  Archives  Generalcs  dc  Mcdeciiie,  July,  ISOG,  vol.  ii.  p.  5. 


186  FRACTURES. 

jaw  horizontally  between  the  alveolar  process  and  the  malar  bone,  and 
Guerin  found  that  pressure  with  the  finger  upon  the  inner  plate  of  this 
process  caused  pain  and  sometimes  showed  mobility  when  there  was  no 
other  sign  of  fracture.  Ecchymosis  of  the  hard  or  soft  palate  indicates 
fracture. 

Repair  in  cases  of  average  severity  takes  place  in  from  thirty  to 
forty  days  with  a  scanty  formation  of  callus,  and  not  infrequently  in 
less  time.  The  vitality  of  the  bone  is  exceptionally  great,  hence  the 
rule  laid  down  by  Malgaigne  and  some  of  his  predecessors,  and 
repeated  by  all  subsequent  writers,  to  leave  every  fragment  that  is  not 
absolutely  and  entirely  detached.  Although  the  rule  is  a  sound  one, 
it  occasionally  happens  that  fragments  become  necrosed  and  have  to  be 
removed.  This  is  thought  to  happen  more  frequently  with  fragments 
of  the  alveolar  border  than  with  any  others. 

Displacement  is  seldom  noticeable  after  repair  is  completed,  except 
in  the  nose,  but  it  usually  exists  to  a  greater  or  less  degree,  and  the 
ingenuity  and  the  patience  of  the  surgeon  are  often  severely  taxed  to 
overcome  the  constant  tendency  to  the  recurrence  of  the  displacement. 
Salivation  is  often  profuse,  and  the  discharge  offensive.  Division  of  the 
lachrvmal  canal  by  the  fracture  may  lead  to  its  obliteration. 

Displacement  of  the  entire  bone  may  be  treated  as  in  Wiseman's 
ease,  or  the  retention  may  be  aided  by  securing  the  lower  jaw  against 
the  upper  one,  with  or  without  the  intervention  of  interdental  splints 
or  moulds  of  gutta-percha  or  metal  shaped  to  fit  the  teeth  and  alveolar 
arch.  Lateral  pressure  cannot  well  be  made  upon  the  cheeks  to  over- 
come separation  along  the  median  line  of  the  palate,  but  fortunately  it 
is  not  always  necessary.  In  Simonin's  case,  quoted  by  Malgaigne,  the 
gap  began  to  contract  spontaneously  by  the  tenth  day,  and  was  com- 
pletely closed  by  the  thirty-third,  with  no  other  displacement  than  a 
slight  difference  in  level  between  the  two  halves.  In  another  case, 
quoted  by  Hamilton,  the  gap  was  large  enough  to  admit  the  little 
finger,  and  was  still  open  six  weeks  after  the  receipt  of  the  injury. 

After  fracture  of  the  alveolar  process  the  fragment  should  be  care- 
fully readjusted  and  fixed  by  wiring  the  teeth  to  the  adjoining  ones,  or 
by  a  splint  of  gutta-percha  or  metal.  Agnew  says  he  has  used  for  this 
purpose  with  great  advantage  a  piece  of  cork  with  grooves  cut  in  its 
upper  and  lower  surfaces  to  receive  the  teeth  of  both  jaws.  The  re- 
duction is  made,  the  cork  inserted,  and  the  jaws  firmly  bound  together. 
1^0  attempt  should  be  made  to  remove  the  corresponding  teeth,  for  not 
only  are  the  chances  in  favor  of  their  becoming  firm  again  in  their 
sockets,  but  the  attempt  to  draw  them,  even  if  they  are  loose,  may 
bring  away  an  important  piece  of  the  bone. 

The  gutta-percha  or  metal  mould  may  be  held  in  place  by  binding 
the  lower  jaw  against  it  after  it  has  been  fitted  to  the  upper  one,  or  by 
an  apparatus  consisting  of  a  band  about  the  head  carrying  two  adjust- 
able rods,  the  lower  ends  of  which  are  bent  to  lie  within  the  mouth. 
If  the  splint  is  to  be  supported  by  the  lower  jaw  it  should  be  so  con- 
structed that  an  interval  will  be  left,  through  which  food  can  be  given 
and  the  mouth  cleansed.  The  cavity  of  the  mouth  should  be  repeat- 
edly cleansed. 


FRACTURES  OF  THE  BONES  OF  THE  FACE.  187 

4.  Fractures  of  the  Inferior  Maxilla. 

Fracture  of  the  inferior  maxilla  occurs  more  frequently  than  that  of 
any  other  of  the  bones  of  the  face.  It  is  rare  in  childhood  and  old 
age,  most  frequent  between  the  ages  of  twenty  and  thirty,  and  is  appar- 
ently more  than  ten  times  as  common  in  males  as  in  females. 

Gurlt  collected  143  published  cases  in  which  the  character  and  posi- 
tion of  the  fracture  were  described  with  sufficient  accuracy  to  allow  of 
their  use  as  statistics  :  of  these  80  were  single,  49  double,  and  in  14 
there  were  three  or  more  lines  of  fracture.  Of  75  single  ones  (exclud- 
ing 5  in  which  the  fracture  was  limited  to  the  alveolar  process)  the 
fracture  occupied  the  median  line  in  25,  the  region  of  the  incisor  teeth 
in  22,  that  of  the  back  teeth  in  15,  behind  the  teeth  in  8,  and  the  con- 
dyloid process  in  5.  In  35  double  fractures  both  halves  of  the  bone 
were  broken  20  times,  and  at  points  on  the  two  halves  corresponding 
closely  with  each  other ;  one  side  alone  8  times,  and  the  median  line 
by  one  of  the  fractures  7  times.  One  or  both  of  the  condyloid  pro- 
cesses were  broken  in  several  of  the  multiple  fractures.  These  figures 
show  that,  exclusive  of  partial  fractures  of  the  alveolar  border,  which 
are  very  common,  and  often  caused  by  the  drawing  of  a  tooth,  the  most 
frequent  seat  of  fracture  is  at  or  near  the  median  line,  and  that  single 
fracture  of  the  ramus,  or  of  the  alveolar  or  condyloid  process  is  com- 
paratively rare.  They  differ  materially  from  the  estimates  made  by 
various  writers,  but  as  the  latter  differ  quite  as  much  among  them- 
selves, and  appear  to  have  spoken  in  most  cases  from  general  impres- 
sions rather  than  from  figures,  the  preference  should  be  given,  I  think, 
to  Gurlt. 

Double  fractures  of  the  lower  jaw  are  relatively  more  common  than 
those  of  other  bones,  while  comminuted  ones  are  rare.  Compound 
fractures  are  common,  both  because  the  gum  overlying  the  fracture  is 
frequently  torn  and  because  the  lip  and  skin  are  often  involved  in  the 
direct  injury  that  has  caused  the  fracture.  The  fracture  is  complete  or 
incomplete,  the  latter  rarely  except  when  the  alveolar  border  alone  is 
involved.  A  portion  of  the  lower  border  of  the  bone  may  be  broken 
off  by  a  blow. 

The  line  of  fracture  in  the  body  of  the  bone  is  usually  vertical  or 
nearly  vertical ;  at  the  angle  or  in  the  ramus  it  is  oblique  or  rarely 
transverse.  At  the  median  line  there  is  but  little  displacement,  if 
any ;  but,  when  present,  it  may  be  in  either  of  three  directions  :  a 
difference  in  the  horizontal  level  of  the  edge  of  the  teeth,  a  displace- 
ment forward  and  backward  of  the  fragments  upon  each  other,  or  a 
lateral  separation  of  the  two.  In  the  fractures  between  the  median 
line  and  the  canine  tooth  the  line  is  still  much  more  frequently  vertical 
than  oblique ;  but  displacement  is  the  rule,  although  no  one  form  of  it 
seems  to  be  more  common  than  the  others.  Between  the  canine  tooth 
and  the  angle  of  the  jaw  it  is  either  vertical  or  inclined  backward  and 
downward,  and  usually,  instead  of  crossing  the  bone  from  without 
inward  at  a  right  angle  to  the  surface,  it  is  inclined  backward  and 
inward,  so  that  the  anterior  fragment  is  lengthened  on  the  inner  side 
and  the  posterior  fragment  on  the  outer  side.  The  inferior  dental 
nerve  is  crossed  by  this  fracture,  and  is  sometimes  torn  or  bruised. 


188  FRACTURES. 

Fracture  behind  the  teeth  is  comparatively  rare,  only  eighteen  cases 
being  contained  in  Giirlt's  statistics,   and  it  is  frequently  double  or 
multiple  or    associated    with    other   fractures. 
Fig.  85.  When  the  fracture  lies  at  the  junction  of  the 

body  of  the  jaw  and  the  ascending  ramus,  it 
is  usually  oblique,  running  from  behind  the 
last  tooth  backward  and  downward  toward  the 
angle  of  the  jaw  ;  but  it  may  be  vertical. 
Displacement  is  usually  slight  or  lacking,  the 
parts  being  kept  well  together  by  the  masseter 
and  internal  pterygoid  muscles  (Fig.  85). 

Fracture  of  the  condyloid  process  is  usually 
accompanied  by  other  fractures  of  the  same 
or  other  bones  of  the  face,  and  may  be  pro- 
Fracture  of  lower  jaw^d    cluf^tl  by  a  blow  either  upon  the  chin  or  upon 
the  teeth.  the  side  of  the  jaw  near  the  joint.     The  line 

of  fracture  passes  through  the  neck,  and  the 
few  specimens  furnished  by  autopsies  and  museums  do  not  show  a 
greater  frequency  at  any  point  or  in  any  direction  than  at  any  other. 

Fracture  of  the  coronoid  process  is  exceedingly  rare  and  has  been  seen 
only  in  association  with  other  fractures  of  the  same  or  adjoining  bones. 
A  portion  of  the  alveolar  process  with  the  teeth  in  place  is  some- 
times broken  off.  The  size  of  the  piece  varies  within  wide  limits,  and 
the  displacement  is  habitually  inward.  In  one  or  two  entirely  excep- 
tional cases  a  similar  piece,  including  a  portion  of  the  body  of  the 
bone,  has  been  broken  off. 

Comminuted  fractures,  except  as  the  result  of  gunshot  wounds,  are  com- 
paratively rare  ;  double  and  treble  fractures  are  less  so;  and  one  case  is 
on  record  in  which  there  were  five  distinct  and  separate  lines  of  fracture. 
A  unique  case  of  coincident  rupture  of  the  facial  artery  was  reported 
by  Cramp.^  He  tied  the  artery  and  the  patient  made  a  good  recovery. 
The  most  frequent  cause  of  fracture,  exclusive  of  partial  fractures 
produced  by  attempts  to  draw  a  tooth,  is  violence  received  upon  the 
chin  ;  fracture  by  pressure  upon  the  sides  is  much  less  common,  the 
other  occurring  thrice  as  frequently.  Fracture  of  the  condyloid  pro- 
cess may  be  produced  in  either  of  the  same  two  ways — a  blow  upon 
the  chin  or  upon  the  cheek. 

The  objective  symptoms  of  fracture  of  the  lower  jaw  are  the  same 
as  those  of  other  fractures  :  abnormal  mobility,  crepitus,  displacement, 
pain.  The  bone  is  so  accessible  to  the  touch  both  within  and  without 
the  mouth  that  irregularities  in  the  outline  of  its  body  can  be  easily 
recognized  by  the  fingers  and  sometimes  by  sight.  The  teeth  show 
differences  in  level,  on  their  tops  or  on  their  sides ;  those  which  adjoin 
the  fracture  are  usually  loosened  and  may  be  entirely  dislodged. 
Mobility  and  crepitus  are  detected  by  manipulation.  When  the  frac- 
ture is  situated  at  or  above  the  angle  of  the  jaw  its  recognition  is  by  no 
means  so  easy ;  by  passing  the  finger  within  the  mouth  along  the  inner 
and  outer  surfaces  of  the  ramus  irregularities  of  outline  and  localized 
points  of  pain  may  be  recognized,  and  pain  at  a  fixed  point  is  caused 
by  biting. 

^  Cramp;  Medical  Record,  Sept  9,  1911. 


FRACTURES  OF  THE  BONES  OF  THE  FACE.  180 

The  degree  and  direction  of  the  displacement  vary  much.  As  a 
rule,  when  the  fracture  is  single  and  lateral,  the  anterior  fragment 
tends  toward  the  inside  of  the  mouth.  In  double  fractures,  the  inter- 
mediate piece  is  almost  invariably  drawn  downward  and  backward  by  the 
unopposed  action  of  the  muscles  of  the  neck  which  are  attached  to  it. 

Fracture  of  the  condyloid  process  was  first  studied  by  Desault  and 
Bichat,  and  but  little  if  anything  has  been  added  to  our  knowledge  of 
the  subject  since  their  time.  The  symptoms  are  pain,  increased  by 
motion,  diminished  mobility  of  the  jaw,  often  crepitus  on  manipulation, 
irregularities  in  the  region  of  the  condyle,  the  ease  with  which  the  con- 
dyle can  be  pushed  forward  into  the  zygomatic  fossa,  its  failure  to  share 
in  the  movements  of  the  jaw,  and  its  almost  constant  displacement 
forward  by  the  contraction  of  the  external  pterygoid.  Ribes  pointed 
out  an  additional  symptom  which  is  sometimes  present,  deviation  of  the 
chin  toward  the  affected  side.  This  is  effected  by  the  displacement  of 
the  ramus  upward  and  backward  on  the  outer  side  of  the  condyle  and 
neck,  and  the  more  easily  if  the  fracture  is  a  double  or  multiple  one. 
Gurlt  quotes  the  description  of  a  specimen  of  this  kind  from  a  work  by 
Bonn,  published  in  1785.  The  condyle  was  united  by  a  bony  callus  to 
the  ramus  just  above  the  orifice  of  the  dental  canal.  I  saw  with  Dr. 
Darrach  a  case  in  which  the  condyle  had  been  displaced  far  inward 
and  so  rotated  that  its  transverse  axis  was  vertical.  The  patient  had 
been  struck  twice  with  the  fist,  once  on  the  cheek  of  the  injured  side, 
and  once  on  the  opposite  side  of  the  chin.  The  displacement  was 
corrected  by  drawing  the  fragment  into  place  through  an  external 
incision. 

Swelling  of  the  gums,  face,  and  glands  follows  promptly  upon  the 
injury,  and  is  often  increased  by  the  direct  bruising  of  the  soft  parts 
themselves;  the  secretions  of  the  mouth,  increased  in  quantity  by  the 
irritation,  mingle  with  the  pus  that  comes  from  the  fracture  if  com- 
pound or  from  the  ulcers  produced  by  the  stomatitis,  decompose,  and 
cause  an  offensive  odor  that  can  scarcely  be  kept  under  control  even  by 
the  most  careful  attention.  Abscesses  may  form  and  open  within  the 
mouth  or  upon  the  sides  of  the  jaw  or  the  neck  below  it;  they  are 
almost  invariably  associated  with  the  presence  of  detached  splinters  or 
the  exfoliation  of  portions  of  the  jaw,  which  require,  of  course,  to  be 
removed  before  a  permanent  cure  can  be  obtained. 

Simple  fractures  unite  in  from  thirty  to  forty  days,  and,  even  when 
there  has  been  a  considerable  loss  of  bone  by  splintering  or  necrosis, 
the  final  result  may  be  a  very  good  one,  in  this  sense,  that  the  jaw  is 
strong  enough  to  support  artificial  teeth  in  place  of  those  that  have 
been  lost  by  the  accident,  is  sufficiently  regular  in  form  to  avoid 
deformity,  and  is  free  in  its  movements. 

Failure  of  union,  pseudarthrosis,  is  rare.  It  is  more  common  after 
fracture  with  much  loss  of  substance,  and  may  interfere  with  mastication. 

The  prognosis  is  a  relatively  favorable  one ;  the  probabilities  are  that 
union  will  take  place  promptly,  that  no  serious  complications  will  arise, 
and  that  no  important  deformity  or  disability  will  remain.  Danger  to 
life  may  come  from  two  quarters;  the  proximity  of  the  bone  to  the 


190 


FRACTURES. 


cranium  carries  with  it  the  possibility  of  associated  injury  to  the  brain 
or  to  its  case;  retention  of  pus  in  a  compound  fracture  in  communica- 
tion with  the  cavity  of  the  mouth  exposes  to  the  grave  danger  of  absorp- 
tion of  the  decomposed  secretions  and,  though  rarely,  to  ttie  burrowino- 
of  the  decomposed  pus  along  the  deeper  planes  of  the  neck  into  the 
anterior  mediastinum. 

Treatment.  Displacement  following  fracture  of  the  bodv  of  the  jaw 
can  usually  be  readily  overcome  by  the  pressure  of  the'  thumb  and 
fingers  upon  the  teeth  and  the  lower  border  of  the  bone  ;  in  some 
cases  the  interlocking  or  wedging  of  the  smaller  pieces  or  of  displaced 
teeth  may  render  the  reduction  impossible  until  after  they  shall  have 
been  removed. 

In  simple  cases  ^yhere  the  tendency  to  displacement  is  slight  it  is 
sufficient  to  immobilize  the  lower  jaw  by  binding  it  against  the  upper 
one  with  a  four-tailed  bandage,  the  centre  of  wliich  is  at  the  chin,  as 
shown  in  Fig;.  86. 


Fig.  86. 


Fig.  87. 


Four-tailed  bandage  for  fracture  of  the 
lower  jaw. 


Kingsley's  splint  applied. 


Splints  are  applied  either  to  the  front  and  under  surface  of  the  jaw 
outside  the  mouth,  or  to  the  teeth,  or  the  inner  surface  of  the  jaw,  and 
two  kinds  are  sometimes  used  in  combination.  Outside  splints  are 
available  only  in  cases  in  which  there  is  not  much  tendency  to  displace- 
ment and  in  which  the  lateral  pressure  of  a  simple  bandage  would 
cause  the  fragments  to  override  in  one  direction  or  another.  They 
may  be  made  of  leather,  pasteboard,  gutta-percha,  or  plaster  of  Paris, 
and  consist  essentially  of  a  cup-shaped  piece  embracing  the  chin  and 
extending  nearly  to  the  angle  of  the  jaw  on  each  side,  and  to  the  fold 
of  the  neck  below. 

Interdental  splints  are  made  of  metal,  gutta-percha,  or  vulcanized 
rubber ;  they  are  fitted  to  the  crowns  of  the  teeth  of  both  fragments 
after  reduction  of  the  displacement,  and  are  held  in  place  either  by 


FRACTURES  OF   THE  BONES  OF   THE  FACE. 


191 


binding  the  jaws  together  with  an  ontside  bandage,  or  by  braces  con- 
necting the  spHnt  with  a  pad  under  the  jaw,  or  by  a  special  arrange- 
ment of  lateral  braces  as  in  Kingsley's  apparatus  (Fig.  87),  or  by 
fastening  them  to  the  teeth  with  wires.  Some  are  fitted  only  to  the 
broken  jaw  and  are  intended  only  to  immobilize  the  fragments  on  each 
other ;  others  are  fitted  to  both  jaws  and  enable  the  upper  one  to  be 
used  as  a  splint  for  the  lower.  Ackland  '  describes  one  capable  of  ready 
adjustment  to  almost  any  fracture  of  the  body  :  a  metal  gutter  partly 
filled  with  softened  gutta-percha,  pressed  down  upon  the  teeth,  and 
secured  to  a  plate  beneath  the  chin  by  two  adjustable  clamps. 

In  one  difficult  case  I  used  a  carpenter's  small  wooden  vise,  one  end 
of  which  lay  on  the  edge  of  the  teeth,  the  other  under  the  chin  ;  after 
a  few  day's  use  the  displacement  ceased  to  recur. 

Gutta-percha  splints  may  be  made  either  of  thin  strips  or  of  thick 
lumps  or  wedges.  The  former  have  a  length  of  three  or  four  inches, 
and  a  breadth  sufficient  to  overlap  the  crowns  of  the  teeth  from  gum  to 
gum  ;  they  are  softened  by  immersion  in  hot  water,  moulded  to  the  teeth, 
cooled  as  rapidly  as  possible,  taken  off,  and  trimmed  suitably.  Then 
the  splint  is  reapplied  and  the  jaws  bound  together.  If  the  tendency 
to  displacement  is  slight  the  bandage  may  be  loosened  during  the  day 
to  allow  the  introduction  of  liquid  food,  or  a  wedge  may  be  kept 
between  the  jaws  so  as  to  create  an  interval  to  be  used  for  this  purpose, 
or  advantage  may  be  taken  of  the  absence  of  teeth,  especially  from  the 
upper  jaw.     In  a  case  quoted  by  Gurlt  ^  two  fragments  of  the  alveolar 


Kingsley's  interdental  splint. 

border  carrying  eight  teeth  were  secured  by  a  splint  of  sheet  lead 
moulded  to  the  teeth  and  fastened  down  by  silver  wire,  the  ends  of 
which  were  brought  out  under  the  chin  by  means  of  a  needle  and  tied 
over  a  roll  of  plaster.  The  wire  caused  no  irritation  and  was  left  in 
place  forty-seven  days. 

Vulcanized  rubber  is  a  valuable  substitute  for  gutta-percha  in  some 
difficult  cases,  but  its  employment  requires  special  skill  and  expei'ience 
which  are  found  usually  only  among  the  dentists.  Casts  of  one  or  both 
jaws  are  first  taken  in  wax;  from  these  plaster  models  are  made,  and 
upon  these  latter  the  splint.    Figs.  87  and  88  show  the  splint  as  made 

1  Ackland:  British  Medical  Journal,  April  1,  1893. 

2  Gurlt:  Loc.  cit.,  vol.  ii.,  p.  393. 


192  FRACTURES. 

by  Dr.  Kingsiey,  of  New  York,  with  attached  bars  by  which  the  spHnt 
and  jaw  can  be  bound  firmly  together,  the  bandage  passing  from  one 
bar  to  the  other  underneath  the  chin. 


Fiu.  89. 

■^ 

^Hpi^^^^^H 

I^H 

^^v/  jf^^^^Kk 

if'M^^^^H 

rntt^^^ 

|[^g'^r>>.^^!^^^^^^B 

li^^^^^^l 

1      Bl 

^^^^^    ^kV 

Matas's  splint. 


The  Matas^  splint  (Figs.  89,  90,  91)  is  said  to  be  easily  adaptable  to 
individual  cases  of  fracture  of  the  body  of  the  jaw,  and  consequently 
of  value  in  hospital  service.  It  consists  of  a  gutter  of  soft  block  tin 
roughly  shaped  to  the  line  of  the  teeth  and  attached  by  hinged  rods  to 


Fig.  90. 


Matas's  splint  for  fracture  of  lower  jaw. 


a  cup-shaped  chin-plate  of  aluminum,  as  shown  in  the  figures.  The 
gutter  is  notched  on  each  side  so  that  it  may  be  more  easily  fitted,  and  it 
should  be  partly  filled  with  dental  wax  so  as  to  fit  snugly  about  the  teeth 

'  Matas:  Annals  of  Surgery,  January,  1905,  p.  1. 


FRACTURES  OF  THE  BONES  OF   THE  FACE. 


193 


Another  method,  which  dates  back  to  Hippocrates,  is  to  fasten 
together  the  teeth  on  opposite  sides  of  the  fracture  by  thread.  In  some 
cases  I  have  found  this  to  answer  perfectly,  in  most  to  fail  entirely. 
The  ligature  should  be  attached  to  the  second  or  third  tooth  from  the 
fracture  on  each  side,  and  should  be  drawn  very  tight. 

A  wire    loop   exactly    moulded    to 

Fig.  91. 


Matas's  splint. 


the  sides  of  the  teeth  and  secured  to  Fig.  92. 

them  at  several  points  by  encir- 
cling loops  (Fig.  92)  has  been  found 
efficient;  also  Angle's^  "  anchor  splint," 
in  which  the  wire  is  attached  to  the 
teeth  by  metal  collars  cemented  on. 
In  a  few  cases  it  has  been  found  effec- 
tual to  bind  the  jaws  together  by 
ligatures  applied  to  opposing  teeth. 

The  problems  created  by  the  vast 
number  of  gunshot  fractures  of  the 
lower  jaw  with  much  loss  of  substance 
observed  in  recent  trench  fighting 
have  led  to  the  exercise  of  much  in- 
genuity and  skill  in  making  and 
adopting  dental  splints,  some  of  which  will  doubtless  be  available  in  the 
simpler  cases  of  civil  practice.    The  remaining  fragments,  after  great 


Hammond's  wire  splint  for  fracture  of  the 

jaw. 


*  Angle:  Medical  Record,  August,  1S90. 


194  FRACTURES. 

loss  of  bone  have  been  successfully  held  in  place  by  fitting  splints  to  the 
teeth  on  each  side  of  the  gap  and  fastening  them  together  by  rods 
extending  across  it.  The  gap  itself  is  filled  in  with  a  graft  of  bone 
or  costal  cartilage. 

Direct  suture  of  the  fragments  by  stout  wire  passed  through  holes 
drilled  well  below  the  alveolar  border  is  said  by  Konig  to  be  the 
method  which  he  has  employed  exclusively  for  several  years.  Others 
have  passed  the  suture  through  holes  drilled  in  the  lower  border  of  the 
bone  through  an  incision  beneath  the  chin. 

Repair  takes  place  so  rapidly  that,  except  in  compound  fracture  with 
much  suppuration,  there  is  rarely  any  tendency  to  displacement  after 
the  tenth  day,  and,  therefore,  the  discomforts  incidental  to  the  contin- 
uous closure  of  the  jaws  do  not  need  to  be  borne  for  any  great  length 
of  time.  If  the  importance  of  the  case  warrants  it,  if  the  displacement 
can  be  prevented  only  by  keeping  the  jaws  constantly  in  contact  with 
each  other,  the  patient  can  be  fed  through  a  tube  passed  behind  the  last 
molar  tooth,  or  through  the  nose,  or  by  the  rectum. 

In  two  fractures  of  the  lower  part  of  the  ramus  Knapp  ■'■  obtained 
good  results  by  pressing  the  anterior  fragment  forward  and  upward  by 
means  of  a  strap  of  adhesive  plaster  crossing  beneath  the  jaw  and  at- 
tached above  to  the  end  of  a  long  piece  of  tin  projecting  in  front  of  the 
forehead  and  shaped  to  the  top  and  back  of  the  head  and  made  fast 
thereto  by  a  plaster-of-Paris  bandage. 

After  fracture  of  the  neck  of  the  condyle  the  tendency  is  to  the  dis- 
placement of  the  condyle  forward  by  the  traction  of  the  external  ptery- 
goid muscle,  and  as  the  fragment  is  too  small  to  be  acted  upon  directly 
by  any  dressing  this  tendency,  if  manifested,  cannot  well  be  overcome. 
The  treatment,  therefore,  is  to  reduce  the  displacement  if  it  exists,  and 
then  to  immobilize  the  jaw  after  hasnng  pressed  it  upward  to  inter- 
lock the  fragments.  Ribes  reduced  the  clisplacement  by  passing  his 
forefinger  into  the  mouth  and  along  the  inner  side  of  the  ascending 
ramus  until  be  reached  the  condyle  and  was  able  to  press  it  back  into 
place.  Fountain  obtained  a  good  result  by  drawing  the  jaw  well  for- 
ward and  wiring  the  teeth  together,  so  as  to  maintain  the  position. 

Fracture  of  the  coronoid  process  is  noit  open  to  any  treatment  except 
immobilization. 

Fractures  of  the  alveolar  border  are  best  treated,  like  fractures  of 
the  body,  by  immobilization  after  careful  reduction  of  the  displace- 
ment, and  it  is  advisable  not  to  make  haste  to  remove  loose  or  semi- 
detached teeth.  They  may  become  firmly  adherent  again,  or,  if  this 
should  fail,  they  may  be  removed  subsequently  without  having  caused 
any  serious  trouble  or  delay. 

1  Knapp:  Medical   News,   February  27,    1904. 


PLATE  V 


Fracture  of  the  Hyoid   Bone. 


CHAPTER  XIII. 

FRACTURES  OF  THE  HYOID  BONE. 

This  comparatively  rare  lesion  has  received  the  attention  of  writers 
onlv  within  the  present  century.  Malgaigne  collected  8  cases,  Hamil- 
ton" added  2,  and  Gibb  3;  in  1864  Gurlt'collected  27  cases,  21  being 
of  the  bone  alone,  while  in  6  there  was  associated  fracture  of  the  thy- 
roid or  cricoid  cartilage  or  of  the  trachea.  I  have  seen  3  of  the 
greater  cornu  and  2  others  were  received  at  the  Hudson  Street  Hospital 
in  1902  and  1903,  which  I  did  not  see.  In  3  of  Malgaigne's  cases  and 
in  5  additional  of  Gurlt's  the  fracture  was  caused  by  hanging,  judicial 
or  suicidal,  one  of  the  latter  surviving  ;  in  6  of  these  one  of  the  greater 
cornua  was  broken,  in  the  remaining  2  the  body.  In  the  other  cases 
of  the  list  the  cause  was  violent  grasping  of  the  neck,  or  a  blow,  or  fall, 
and  in  2  cases  apparently  muscular  action,  general  muscular  contrac- 
tion during  a  fall. 

In  the  great  majority  of  the  cases  the  fracture  was  of  one  of  the 
greater  cornua,  and  usually  at  or  near  its  junction  with  the  body.  In 
only  three  cases  was  the  body  of  the  bone  broken,  and  in  none  the 
lesser  horn. 

In  the  light  of  later  observations  it  seems  that  some  of  the  reported 
cases  may  well  have  been  sprains  or  dislocations  of  the  joint  sometimes 
existing  between  the  greater  horn  and  the  body,  and  others  a  displace- 
ment of  the  posterior  end  of  the  greater  horn  from  the  thyroid  cartilage, 
the  so-called  dysphagia  Valsaviana.  (See  Chapter  XXXVII,  subluxa- 
tions of  the  hyoid  bone.) 

Anatomy.  The  bone  develops  by  five  centers  of  ossification:  one 
for  the  body  and  one  for  each  of  the  horns.  The  lesser  horns  remain 
separate  from  the  body,  the  greater  horns  generally  unite  with  it  by 
bony  union  rather  late  in  life,  but  sometimes  form  a  real  joint  with  it. 

Symptoms.  The  symptoms  of  fracture  of  one  of  the  larger  cornua, 
without  accompanying  injury  to  the  larynx  or  trachea,  are,  according 
to  the  records,  quite  well  defined  and  characteristic  :  sharp  pain  at  the 
seat  of  fracture  increased  by  pressure,  speaking,  or  swallowing ;  swell- 
ing in  the  same  region  appearing  soon  after  the  accident  and  due  in 
part  to  extravasated  blood  ;  recognizable  displacement  or  mobility  of 
the  fragment ;  crepitus ;  and  sometimes  free  bleeding  into  the  mouth, 
the  result  of  perforation  of  the  mucous  membrane  of  the  pharynx  by 
the  bone.  Exploration  of  the  pliarynx  will  enable  the  surgeon  to 
recognize  displacement  of  the  horn  inward  and  perforation  of  tlie 
mucous  membrane  if  they  exist.  The  patient  is  seldom  able  to  move 
the  tongue  freely  or  without  pain,  and  in  some  cases  attempts  to 
depress  it  or  put  it  out  have  caused  paroxysms  of  suffocation.  In  all 
the  cases  it  has  been  difficult  to  swallow,  even  a  drop  of  water  some- 
(  195  ) 


196  FRACTURES. 

times  causing  the  patient  to  cough  and  choke,  and  in  many  of  them  it 
was  necessary  to  give  food  through  an  oesophageal  tube,  in  one  case 
for  twenty  days.  In  my  own  cases  there  was  locaUzed  pain  on  press- 
ure, and  the  mobihty  of  the  cornu  could  be  recognized  by  grasping  the 
bone  with  the  thumb  and  finger  on  either  side  of  the  neck.  The  sub- 
jective symptoms  were  not  urgent  except  when  fracture  of  the  larynx 
was  associated;  one  such  died  by  suffocation  while  tracheotomy  was 
being  done. 

In  the  single  case  in  which  a  fracture  of  the  body  of  the  hyoid  bone 
was  observed  during  life  the  symptoms  were  severe  paroxysms  of 
coughing,  dyspnoea,  lividity  of  the  face,  and  abundant  bloody  sputa, 
and  were  relieved  by  the  reduction  of  the  displacement. 

The  local  and  general  reaction  after  the  injury  has  been  quite 
marked  and  although  the  bone  appears  to  have  united  promptly  con- 
valescence has  been  delayed  by  the  persistence  of  the  dysphagia  and 
of  the  change  in  the  voice.  In  two  cases  an  abscess  formed  at  the  seat 
of  fracture,  and  three  months  afterward  the  necrosed  posterior  frag- 
ment was  cast  out.  In  an  unreported  case  of  which  I  have  heard  a 
sluggish  abscess  without  necrosis  formed,  and  the  diagnosis  was  made 
when  the  pus  was  evacuated. 

The  possibility  of  repair  by  a  bony  callus  is  shown  by  three  speci- 
mens :  one,  taken  from  the  body  of  an  adult  man  without  a  history 

and  presented  to  the  London  Patho- 
*'^<*-  93.  logical    Society    by    Gibb,    showing   a 

fracture  of  the  right  greater  horn  which 
had  united  with  overriding  to  the  ex- 
tent of  one-quarter  of  an  inch,  and  dis- 
placement inward ;  another  (Fig.  93) 
in  the  pathological  collection  of  the 
college  at  Brunswick,  showing  a  frac- 
ture of  the  right  greater  horn  united 
with  some  shortening  and  displacement 
downward ;  the  third,^  found  in  the 
dissecting-room,  a  fracture  at  the  junc- 
tion of  the  left  cornu  and  body,  united 
^,  .,  , ,    ,        r.i.  T,     J,-  with  angular  displacement. 

United  fracture  of  the  hyoid  bone.  '='    .  ^p,/  .  „ 

(GuRLT.)  Prognosis.     Ihe  prognosis,  so  tar  as 

life  is  endangered  by  the  injury  to  the 
bone,  is  favorable,  but  the  associated  injuries  in  the  recorded  cases 
have  often  been  such  as  to  cause  death.  Among  these  associated  inju- 
ries fracture  of  the  larynx  is  prominent. 

Treatment.  The  treatment  requires  the  reduction  of  displacement, 
if  possible ;  and  this  might  be  facilitated  by  the  introduction  of  the 
finger  into  the  pharynx.  It  is  unlikely  that  a  bandage  would  be  of 
any  service  in  opposing  a  tendency  to  the  recurrence  of  displacement. 
Immobilization  of  the  head  and  neck  by  a  stitf  collar  lias  been  sug- 
gested. 

The  dysphagia  may  render  nourishment  through  an  oesophageal  tube 
necessary,  and  associated  injury  of  the  larynx  may  require  tracheotomy. 
1  Scriber:  Medical  Age,  Detroit,  January,  1892. 


CHAPTER  XIV. 

FEACTUKES  OF  THE  CARTILAGES  OF  THE  LARYNX  AND 

TRACHEA. 

This  injury,  although  actually  rare,  is  more  frequent  and  much  more 
dangerous  than  fracture  of  the  hyoid  bone  and  has  received  more  atten- 
tion from  writers.  Gurlt's  collection  published  in  1864  contained  47 
cases,  Dr.  Hunt  ^  collected  and  analyzed  27  cases  but  did  not  give  the 
details,  and  Henoque  ^  collected  52  cases,  to  which  Mr.  Durham^  added 
10,  making  62  in  all,  or  including  4  of  Gurlt's  in  which  tlie  trachea 
alone  was  injured,  66.  Piatt*  reports  one  terminating  fatally  by 
broncho-pneumonia  in  three  days,  and  Stephens^  one  combined  with 
fracture  of  the  hyoid,  followed  by  death  in  a  few  minutes. 

The  following  table  shows  the  relative  frequency  with  which  the 
different  parts  are  affected  : 


Cartilage  broken. 

Cases. 

Deaths. 

Recoveries. 

Tliyroid  alone  ..... 

.     24 

18 

6 

Cricoid  alone 

.     11 

11 

Thyroid  and  hyoid  bone  . 

5 

3 

2 

"          "    cricoid 

.       9 

9 

"          "         "       and  hyoid  bone 

.       2 

2 

"          "         "         "    trachea 

.       2 

2 

Cricoid  and  trachea 

.       2 

2 

"        ''         "         and  hyoid  bone 

1 

1 

"  Larynx  " 

7 

3 

4 

Trachea  alone 

.      4 

3 

1 

67  54  13 

The  causes  are  blows,  falls,  hanging,  and  the  grasp  of  the  hand  in 
a  fight,  or  in  an  attempt  to  strangle.  The  injury  is  seen  more  fre- 
quently in  males  than  in  females,  and  in  middle  life  than  at  any  other 
])eriod,  but  youth  and  old  age  are  not  exempt.  The  mechanism  of  the 
fracture  of  the  thyroid  or  cricoid  is  usually  either  lateral  compression  on 
both  sides  or  pressure  backward  against  the  vertebral  column  ;  the  first 
causes  commonly  longitudinal  fracture  of  the  thyroid  cartilage  near  its 
middle,  together  with  flattening  or  depression  of  its  sides,  and  either  a 
double  lateral  fracture  of  the  cricoid  cartilage  or  a  single  fracture  in  the 
anterior  median  line  ;  the  second  causes  irregular  and  multiple  lines  of 
fracture.  The  mucous  membrane  of  the  larynx  is  frequently  torn,  and 
extravasations  of  blood  take  place  under  the  skin  and  mucous  mem- 
brane or  among  the  muscles. 

1  Hunt:  American  Journal  of  the  Medical  Sciences,  April,  1806,  p.  378. 

''■  Henoque:  Gazette  Hebdoraadaire,  Sept.  26  and  Oct.  2,  1868. 

■'Holmes's  System  of  Surgery,  American  edition,  vol.  i.  p.  697. 

*  Piatt :  Med.  Chronicle,  Dec,  1899. 

^Steihens:  Guy's  Hospital  Eeport.s,  vol.  liv,,  1900. 

(  197  ) 


198  FRACTURES. 

Symptoms. — The  symptoms  of  fracture  of  the  larynx  are  frothy 
bloody  expectoration  with  convulsive  coughing  and  usually  much 
dyspnoea  and  its  attendant  symptoms.  The  voice  is  affected  or  lost, 
and  swallowing  often  difficult  and  painful,  although  not  so  much  so  as 
after  fracture  of  the  hyoid  bone ;  and  in  all  severe  cases,  when  there 
is  laceration  of  the  mucous  membrane,  emphysema  appears  promptly 
and  spreads  steadily  over  the  neck,  face,  trunk,  the  extremities,  and 
mediastinum,  being  sometimes  more  marked  in  the  intermuscular  than 
in  the  subcutaneous  connective  tissue  and  sometimes  causing  pneumo- 
thorax without  wound  of  the  lung. 

The  additional  objective  symptoms  are  deformity  of  the  region  and 
abnormal  mobility  of  parts  of  the  larynx  upon  each  other,  but  both 
these  signs  may  be  unrecognizable  on  account  of  the  swelling.  I  have 
seen  one  case  in  which  the  only  symptom  was  the  mobility  with  crep- 
itus of  a  small  fragment  at  the  upper  posterior  angle  of  the  larynx ; 
there  was  also  slight  hoarseness. 

In  some  cases  there  have  been  no  marked  symptoms  beyond  a  change 
in  the  voice,  although  the  character  of  the  injury  was  made  clear  by 
careful  examination,  and  the  difference  seems  to  be  due  to  the  absence 
in  these  cases  of  any  obstruction  or  narrowing  of  the  air-passages  by 
displacement  or  swelling. 

The  course  in  the  severe  cases  is  toward  prompt  death  by  suffocation, 
either  by  gradual  increase  of  the  dyspncea  or  by  the  sudden  intercur- 
rence  of  oedema  of  the  glottis.  Occasionally  the  dyspnoea  does  not 
make  its  appearance  until  some  days  after  the  injury.  In  the  mild 
cases  the  symptoms  gradually  subside,  and  recovery  follows. 

It  seems  probable  that  repair  is  by  a  bony,  or  at  least  by  a  calcified, 
callus. 

Treatment.  The  treatment  in  the  milder  cases  consists  of  local  anti- 
phlogistics  and  quiet ;  in  the  severer  ones,  of  tracheotomy  whenever 
the  dyspnoea  is  great  or  increasing.  It  is  not  safe  to  wait  until  it  has 
become  extreme,  for  its  increase  at  the  last  is  often  so  rapid  and  sudden 
that  death  takes  place  before  relief  can  be  given.  It  is,  therefore,  the 
part  of  prudence  to  interfere  early  and  before  the  interference  is  made 
actually  necessary  by  the  defective  breathing.  Advantage  should  be 
taken  of  the  opportunity  afforded  by  the  operation  to  reduce  any  dis- 
placement that  may  exist  and  that  can  be  overcome  by  manipulation 
through  the  wound. 

Trachea.  The  symptoms  of  fracture  of  the  trachea  are  similar  to 
those  of  fracture  of  the  larynx,  except  the  local  ones  due  to  the  dis- 
placements ;  the  diagnosis  is  difficult  because  of  the  lack  of  symptoms 
distinctive  of  the  seat  and  character  of  the  lesion.  The  prognosis  is 
unfavorable,  and  the  treatment  has  usually  been  insufficient  to  avert 
the  fatal  termination  or  relieve  the  suffering,  because  in  the  few 
recorded  cases  the  seat  of  injury  has  been  beyond  reach  by  operation. 
The  indication  for  treatment  is  to  insert  a  tube  into  the  trachea  past 
the  point  of  fracture  so  as  to  insure  free  breathing. 


CHAPTER  XV. 

FRACTURES   OF   THE  STERNUM. 

The  sternum,  formed  originally  of  several  pieces,  has  an  irregular 
and  uncertain  development,  only  one  feature  of  which  needs  here  to 
be  mentioned.  The  upper  portion,  the  manubrium,  may  unite  by 
ossification  with  the  central  portion,  the  body,  at  some  time  during 
adult  life,  and  in  such  case  a  traumatic  separation  of  the  two  portions 
is  a  fracture,  not  a  dislocation. 

Fracture  is  rare,  almost  unknown,  before  the  age  of  twenty  years, 
and  is  frequently  associated  with  other  fractures,  especially  of  the  ribs 
and  vertebrae.  The  fracture  may  be  incomplete,  multiple,  transverse, 
oblique,  or  longitudinal.  Of  the  first  form  there  are  but  two  recorded 
instances  ;  in  both  the  infraction  occupied  the  posterior  surface  of  the 
bone  at  or  near  tiie  junction  of  the  lower  and  middle  thirds  and  was 
accompanied  by  an  abundant  extravasation  of  blood  into  the  anterior 
mediastinum. 

Of  compound  fractures,  except  such  as  were  gunshot  or  stab  wounds, 
there  is  but  one  example,  reported  by  Duverney  in  1751.  A  quarry- 
man,  while  at  work  lying  upon  his  side,  was  caught  under  a  heavy 
stone  about  five  feet  long  which  compressed  his  chest  laterally  with 
such  force  as  to  separate  the  middle  portion  of  the  sternum  from  the 
upper  portion  and  force  it  through  the  skin.  Death  was  immediate, 
by  rupture  of  the  heart  and  lungs. 

Of  pure  longitudinal  fracture  there  is  but  one  certain  example,  but 
there  are  two  other  cases  in  one  of  which  there  was  a  longitudinal  frac- 
ture of  the  manubrium,  and  in  the  other  of  the  body  of  the  sternum 
associated  with  a  transverse  fracture  at  its  upper  end.  The  first  case 
was  that  of  a  man  who  was  overthrown  and  crushed  by  a  falling  wall ; 
in  addition  to  numerous  contusions,  the  sternum  was  broken  longitu- 
dinally through  its  entire  length,  the  right  half  being  depressed 
from  eight  to  ten  lines  below  the  level  of  the  left  half.  There  was 
profuse  bloody  expectoration  and  difficult  breathing.  Reduction  was 
accomplished  by  drawing  the  right  arm  back  and  making  forcible  press- 
ure upon  the  middle  of  the  sternal  ribs  of  the  right  side  and  gentle 
pressure  upon  the  left  side.     The  patient  recovered  in  six  weeks. 

Cases  of  congenital  fissure  of  the  sternum  have  been  mistaken  for 
longitudinal  fracture. 

Simple  transverse  fractures  form  the  great  majority  of  fractures  of 
the  sternum,  and  occupy  most  frequently  the  junction  between  the 
manubrium  and  the  body  of  the  bone  or  its  immediate  neighborhood — 
that  is,  the  region  of  the  second  intercostal  space ;  next  in  frequency 
are  fractures  at  or  near  the  middle  of  the  bone,  corresponding  to  the 
14  ( 199  ) 


200 


FRACTURES. 


third  rib  and  the  third  intercostal  space ;  they  are  rarely  high  in  the 
manubrium  and  below  the  middle  of  the  body,  and  very  uncommon  as 
separations  of  the  ensiforra  appendix  from  the  body. 

Fractures  of  the  manubrium  occur  most  commonly  a  short  distance, 
two  or  three  lines,  above  its  lower  border ;  the  periosteum  sometimes 
remains  untorn  upon  either  the  anterior  or  the  posterior  surface ;  in 
some  cases  there  has  been  no  displacement,  in  others  either  the  upper  or 
the  lower  fragment  has  been  displaced  forward,  and  in  one  case  there  was 
angular  displacement,  the  apex  of  the  angle  being  directed  backward. 
In  several  of  the  cases  the  fracture  was  produced  by  muscular  action, 
by  straining  during  childbirth,  or  by  the  effort  to  raise  a  heavy  weight 
with  the  teeth,  the  back  being  bent  far  back.  In  a  large  proportion 
of  cases  in  which  the  lesion  was  produced  by  external  violence  there 
was  also  fracture  of  the  ribs,  clavicle,  or  vertebrae. 

Fig.  94. 


Fracture  oi  the  sternum. 


Fractures  of  the  border  have  been  observed  in  three  instances,  once 
in  connection  with  fracture  of  the  ribs,  a  scale  of  bone  corresponding 
to  the  articulation  with  the  first  rib  being  broken  off;  a  second  time  in 
connection  with  dislocation  of  the  sternal  end  of  the  clavicle,  the  por- 
tion to  which  the  sterno-cleido-mastoid  was  attached  being  torn  off  and 
drawn  upward  nearly  half  an  inch  ;  and  in  a  third  case  in  connection 
with  a  transverse  fracture  lower  down. 


FRACTURES  OF  THE  STERNUM. 


201 


Transverse  fracture  at  or  near  the  junction  of  the  manubrium  and 
body  of  the  bone,  and  diastasis  at  this  point,  which  is  not  always  to  be 
distinguished  from  fracture,  are  the  commonest 
forms  of  injury.  In  the  great  majority  of  cases  the 
lower  fragment  is  displaced  so  as  to  lie  in  front  of 
the  upper  one,  and  sometimes  to  override  ;  it  is  ex- 
ceptional for  displacement  to  be  absent  or  for  the 
upper  fragment  to  lie  in  front  of  the  lower  one. 

There  is  reason  to  think  that  the  periosteum  is 
almost  invariably  torn  upon  the  anterior  surface, 
but  that  it  sometimes  remains  untorn  behind,  a 
fact  M'hich  derives  considerable  importance  from 
its  bearing  upon  the  escape  of  blood  into  the  ante- 
rior mediastinum.  One  or  both  of  the  second  pair 
of  ribs  usually  remain  attached  to  the  manubrium. 

Out  of  a  total  of  105  cases  of  fracture  of  the 
sternum  collected  by  Gurlt,  27  are  described  as 
partial  or  complete  diastasis  at  the  junction  of  the 
first  and  second  portions,  the  character  of  the  lesion 
having  been  determined  by  post-mortem  examina- 
tion in  fourteen  of  them. 

Fractures  of  the  body  of  the  sternum  (Fig.  95) 
occur  most  frequently  between  the  second  and 
fourth  costal  cartilages,  are  usually  transverse,  but 
sometimes  oblique  laterally  or  from  before  back- 
ward. The  displacements  are  the  same  as  after 
fracture  at  the  junction  of  the  manubrium  and 
sternum,  and  there  is  the  same  relative  frequency  of  the  projection  of 
the  lower  fragment. 

Comminuted  fracture  of  the  body  of  the  sternum  has  been  rarely 
seen  except  in  connection  with  gunshot  and  punctured  wounds.  Of 
triple  fractures  Gurlt  found  only  two  cases,  and  of  double  fractures 
only  six,  all  of  them  associated  with  fracture  of  other  bones,  usually 
the  ribs  or  vertebrae. 

Of  fracture  or  diastasis  of  the  ensiform  appendix,  Gurlt  collected 
only  four  examples,  and  the  list  does  not  appear  to  have  been  increased 
by  subsequent  writers ;  one  was  a  fracture,  the  other  three  diastases. 
The  fracture  was  produced  in  a  man  sixty  years  old  by  a  fall  upon  the 
sharp  edge  of  a  grain  measure,  and,  when  last  examined,  nine  months 
after  the  accident,  was  still  ununited,  and  crepitated  on  pressure,  but 
caused  no  inconvenience.  In  the  other  three  cases  the  prominent  symp- 
tom was  persistent  vomiting,  which  in  one  lasted  for  two  years,  recurring 
every  five  or  six  days,  and  then  ceased  spontaneously ;  in  another  it 
was  cured  by  grasping  the  process  between  two  fingers  and  bending  it 
back  into  place ;  and  in  the  third,  after  it  had  lasted  a  month  and 
death  by  exhaustion  seemed  imminent,  it  was  instantly  relieved  by 
the  reduction  of  the  displacement,  which  was  accomplished  by  in- 
serting a  blunt  hook  into  the  abdominal  cavity  through  an  incision, 
and  drawing  the  process  forward.  The  patients  were  aged  respectively 
twenty-eight,  eighteen,  and  nineteen  years. 


Transverse  fracture 
of  the  body  of  the 
sternum. 


202  FRACTURES. 

The  eifusiou  of  blood,  which  is  observed  after  all  fractures,  may 
attain  an  especial  importance  after  fracture  of  the  sternum,  by  the 
pressure  which  it  may  exert  upon  the  underlying  heart.  The  blood, 
coming  from  the  torn  vessels  of  the  bone  and  periosteum,  makes  its 
way  forward  into  a  region  where  it  can  do  no  harm  if  the  periosteum 
on  the  posterior  surface  remains  untorn  ;  but  if  this  membrane  shares 
in  the  injury,  and  especially  if  one  of  the  internal  mammary  veins  or 
arteries  is  ruptured,  the  blood  makes  its  way  into  the  anterior  medias- 
tinum, and  sometimes  in  sufficient  amount  to  cause  death  promptly. 

Rupture  of  the  pericardium,  or  of  the  heart,  has  been  observed  in  a 
few  cases;  as  has  also  probable  laceration  of  the  lung,  evidenced  by 
the  appearance  of  subcutaneous  emphysema  or  pneumothorax. 

Etiology.  Fracture  of  the  sternum  may  be  produced  either  by  mus- 
cular action  or  by  external  violence. 

There  are  four  recorded  cases  in  which  the  bone  has  been  broken  by 
straining  during  labor,  and  three  in  which  the  fracture  has  occurred 
during  an  effort  to  lift  a  heavy  object. 

External  violence  acts  either  directly  by  a  blow  upon  the  breast,  or 
indirectly  by  forcibly  bending  the  body  forward  or  backward,  or  pos- 
sibly by  a  combination  of  the  two  forms  in  the  fall  upon  the  body  of 
a  heavy  object,  or  the  passage  across  it  of  a  loaded  wagon,  or,  according 
to  Lane,  by  depression  of  the  shoulder  acting  through  the  clavicle  and 
the  upper  ribs.  It  is  not  necessary  that  the  force  which  acts  directly 
should  be  very  great  to  produce  fracture ;  it  is  sufficient  for  it  to  act 
upon  a  limited  area,  as  in  a  fall  upon  a  stone,  or  stick,  or  the  edge  or 
corner  of  a  box. 

The  violence  which  produces  indirect  fracture  is,  in  most  cases,  a  fall 
either  upon  the  shoulders  or  buttocks,  or  with  the  back  or  breast  across 
some  fixed  object,  so  that  the  trunk  is  bent  sharply  forward  or  back- 
ward ;  in  the  one  case  the  bone  is  broken  by  being  bent  forward,  in  the 
other  by  traction  exerted  through  the  muscular  attachments  at  either 
end. 

Diagnosis.  The  diagnosis  is  readily  made  by  the  objective  symp- 
toms— the  displacement,  mobility,  and  crepitus — and  by  the  localized 
area  of  pain  excited  by  pressure,  change  of  position,  and  the  more 
forcible  respiratory  acts.  I  have  seen  a  few  cases  in  wliich  the  only 
symptom  was  pain  on  pressure,  with  late  ecchymosis.  The  examination 
of  the  bone  must  be  made  carefully  in  order,  on  the  one  hand,  to  avoid 
mistaking  sonie  irregularity  of  development  for  a  traumatic  displace- 
ment, and,  on  the  other,  not  to  overlook  a  second  or  third  fracture,  or 
even  a  single  one  in  case  there  should  be  no  displacement.  In  cases 
of  supposed  injury  to  the  ensiform  appendix  the  frequent  irregularities 
in  the  shape,  position,  and  mobility  of  that  part  must  be  borne  in  mind. 

The  importance  of  the  injury  is  by  no  means  so  great  as  the  mor- 
tality of  the  recorded  cases  would  indicate,  for  this  mortality  is  largely 
due  to  associated  lesions.  Gurlt  tabulated  98  cases  with  reference  to 
this  point,  among  others,  and  found  that  of  54  simple  cases  46  recov- 
ered and  8  died,  while  of  44  complicated  cases,  cases,  that  is,  in  which 
there  was  some  severe  associated  injury,  only  1  recovered  and  43  died. 
Of  20  cases  in  which  the  fracture  was  certainly  caused  by  direct  vio- 


FBACTURES  OF  THE  STERNUM.  203 

leuce,  15  recovered  and  5  died,  3  of  the  latter  being  complicated 
cases. 

Course.  The  course  in  the  uncomplicated  cases  is  uneventful ;  if  pain 
and  oppression  are  marked  at  first  they  soon  diminish  and  disaj)pear,  as 
do  also  expectoration  of  blood,  dyspnoea,  and  orthopnea.  The  principal 
danger  is  from  pulmonary  complications,  especially  in  the  old  and 
alcoholic.  In  exceptional  cases  the  local  reaction  may  be  great  and 
may  lead  even  to  the  formation  of  an  abscess  about  the  fracture.  The 
pus  may  make  its  way  to  the  surface  between  the  fragments  or  on  the 
sides,  and  if  it  collects  upon  the  posterior  surface  and  is  discharged 
imperfectly  through  a  small  opening,  the  sinus  may  persist  indefi- 
nitely, or  the  unnatural  conditions  may  lead  to  extensive  caries  of  the 
bone.  Both  conditions  require  treatment  by  active  operative  inter- 
ference. 

Usually  repair  takes  place  in  from  four  to  eight  weeks,  and  by  a 
bony  callus.  The  persistence  of  a  certain  degree  of  displacement  is 
not  uncommon,  and  in  some  cases  the  deformity  has  been  extreme. 

Failure  of  bony  union  has  been  observed  in  a  few  cases,  but  does 
not  appear  to  have  caused  any  disability  beyond  a  temporary  difficulty 
in  abduction  and  adduction  of  the  arms. 

Gunshot  fractures  may  be  penetrating  or  non-penetrating.  A  num- 
ber of  illustrative  cases  of  each  kind  are  given  in  the  Surgical  History 
of  the  War  of  the  Rebellion.  The  latter  do  not  differ  materially  from 
compound  fractures  due  to  any  other  cause,  but  in  the  former  the  prog- 
nosis is  rendered  very  grave  by  the  associated  lesions. 

Treatment.  The  first  indication  is  to  reduce  such  displacement  as 
may  exist.  This  is  not  always  possible  ;  the  most  intelligently  directed 
and  persistently  conducted  efforts  have  sometimes  failed.  The  usual 
method  is  direct  pressure  upon  the  projecting  fragment,  aided,  espe- 
cially when  there  is  overriding,  by  traction  upon  the  two  pieces.  The 
traction  must  be  made,  in  part  at  least,  through  the  muscles  attached 
to  the  ends  of  the  bone,  and  is  accomplished  sometimes  by  resting  the 
back  upon  some  rather  firm  object,  as  a  cushion  or  box,  and  bending 
the  head  and  shoulders  forcibly  backward.  At  the  same  time  the 
patient  may  be  directed  to  take  a  full  inspiration,  and  tiie  surgeon 
presses  downward  against  the  upper  edge  of  the  lower  fragment  if  that 
one,  as  is  usual,  projects,  or  he  draws  this  fragment  downward  by 
taking  hold  of  the  projecting  ribs  that  are  attached  to  it.  Various 
modifications  of  the  plan  have  been  employed,  but  all  have  the  same 
fundamental  idea,  that  of  traction  in  opposite  directions  upon  the  frag- 
ments by  forcible  bending  of  the  body  backward.  In  one  case  reduc- 
tion was  gradually  effected  in  three  days  by  keeping  the  patient  recum- 
bent, with  the  head  and  shoulders  thrown  back. 

A  number  of  operative  methods  have  been  proposed  fi)r  use  in  those 
cases  in  which  the  displacement  cannot  be  reduced  by  manipulatif)n, 
such  as  to  raise  the  depressed  fragment  by  a  sort  of  gimlet  screwed 
into  it,  or  by  an  elevator  or  blunt  hook  passed  under  it  through  an 
incision,  or  to  cut  away  the  projecting  portion,  or  to  press  it  back  with 
a  rod  carried  directly  down  to  it  through  an  incision.  Most  of  these 
remain  as  suggestions  that  have  not  been  put  to  the  test.     One  case 


204  PBAGTVRE&. 

has  been  already  mentioned  in  which  the  ensiform  appendix  was  drawn 
forward  successfully  by  means  of  a  blunt  hook  passed  into  the  per- 
itoneal cavity ;  in  another,  of  fracture  at  the  upper  part  of  the  sternum 
with  depression  of  the  lower  fragment,  an  incision  was  made  with  the 
inteution  of  introducing  a  hook,  but  the  pleural  cavity  was  opened 
and  the  surgeon  felt  it  necessary  to  close  the  wound  immediately.  In 
another  the  upper  fragment  was  raised  to  the  proper  level  by  screwing 
a  sort  of  gimlet  into  it  and  drawing  it  forward,  but  it  afterward  sank 
partly  back  again,  and  a  second  attempt  to  raise  it  was  defeated  by  the 
tearing  of  the  screw. 

Unless  the  displacement  is  actually  causing  dangerous  or  distressing 
symptoms  these  methods  of  removing  it  by  operation  are  hardly  justi- 
fiable, because  they  carry  with  them  risks  that  should  not  be  lightly 
run. 

The  subsequent  treatment  consists  in  immobilization  of  the  chest, 
and,  if  necessary,  in  the  use  of  measures  to  allay  local  inflammation 
and  to  prevent  coughing.  A  convenient  dressing  is  a  broad  flannel 
bandage  pinned  tightly  about  the  chest  after  forced  expiration,  or  bands 
of  adhesive  plaster  extending  from  side  to  side  across  the  front  of  the 
chest  and  covering  the  entire  length  of  the  sternum. 

If  the  formation  of  pus  behind  the  bone  is  recognized  or  suspected 
it  should  be  promptly  sought  for  and  evacuated  by  cutting  through  the 
bone  at  the  seat  of  fracture. 


CHAPTER    XVI. 

FRACTURES  OF  THE  RIBS  AND   THEIR   CARTILAGES. 
Fractures  of  the  Ribs. 

These  are  among  the  commonest  of  all  fractures,  more  common  in 
men  than  in  women,  and  almost  unknown  (or  unrecognized)  in  infancy 
and  childhood  ;  probably  many  cases  pass  unrecognized,  and  the  fre- 
quency is  even  greater  than  the  statistics  show. 

Pathology.  The  fracture  may  bo  partial  or  complete,  simple  or  com- 
pound, single  or  nuiltiple.  Partial  fractures  may  be  constituted  either 
by  a  fissure  involving  only  one  of  the  borders  of  the  rib  and,  ])erhaps, 
separating  entirely  a  longer  or  shorter  fragment  of  that  border,  or  by 
an  infraction.     The  former  is  very  uncommon. 

Complete  fractures  may  be  transverse,  oblique,  irregular,  or  multiple, 
and  may  be  limited  to  a  single  rib,  or  may  involve  all  the  true  ones  on 
one  side,  and  in  some  cases  even  many  on  both  sides.  The  central 
ribs  are  the  ones  most  frequently  broken.  Fracture  of  the  twelfth  is 
very  rare;  Gurlt  could  find  only  two  recorded  cases,  the  causes  being 
a  fall  against  the  edge  of  a  step  and  a  table  respectively.  I  saw  one 
at  the  Hudson  Street  Hospital  in  1896,  in  a  man,  fifty  years  old,  who 
had  been  caught  about  the  waist  in  the  loop  of  a  hawser.  He  died  a 
few  days  later  of  coincident  rupture  of  the  large  intestine ;  the  twelfth 
rib  was  broken  obliquely  at  its  centre.  For  another  case,  see  Chapter 
XL.,  Dislocation  of  Head  or  Rib.  In  1905  I  saw  another,  a  sailor 
carried  by  a  wave  against  the  corner  of  a  hatch. 

Fracture  of  the  first  rib  was  formerly  thought  to  be  almost  equally 
rare,  but  the  observations  of  Lane  ^  and  Marsh  -  indicate  tiiat  fracture 
of  it  or  its  cartilage  may  be  rather  common.  Lane  found  four  speci- 
mens in  a  series  of  200  bodies  in  the  dissecting-room,  and  Marsh  saw 
four  cases  in  six  months'  hospital  service.  According  to  Lane  this  rib 
is  easily  broken  by  forcible  depression  of  the  shoulder  acting  by  direct 
pressure  of  the  clavicle.  The  symptom  is  said  to  be  pain  behind  the 
upper  part  of  the  sternum  on  lifting  with  the  corresponding  hand. 

The  fracture  of  a  rib  may  occupy  any  part  of  it,  but  is  most  fre- 
quent on  the  side  and  anterior  half.  The  periosteum  may  remain 
untorn,  and  the  fragments  preserve  their  relations  to  each  other,  or 
they  may  form  a  re-entrant  or  a  salient  angle,  or  override  each  other. 
If  several  ribs  are  broken  at  the  same  time  and  forced  inward  the 
depression  may  remain  both  broad  and  deep.  Overriding  of  the  frag- 
ments is  impossible  unless  several  ribs  are  broken  at  the  same  time, 
for  the  muscular  and  fibrous  attachments  to  the  adjoining  ones  hold  the 
fragments  in  place,  and  the  ribs  above  and  below  act  as  splints  to  pre- 

1  Lane:  British  Medical  Journal,  1887,  vol.  ii,  p.  119;  and  Guy's  Hospital  Reports, 
1886,  p.  429. 
■     2  Marsh:  Lancet,  June  30,  1888. 

(  205  ) 


206  FRACTURES. 

vent  shortening.  In  double  or  multiple  fracture  of  one  or  several  ribs 
the  intermediate  piece  or  pieces  may  be  so  loosened  that  they  move  in 
and  out  with  every  inspiration. 

In  compound  fractures  the  wound  of  the  soft  parts  is  rarely,  if  ever, 
caused  by  the  projection  of  the  broken  end  of  the  rib,  but  always  by 
the  object  which  produced  the  fracture. 

The  compHcations  include  injuries  to  the  muscles,  which  are  rarely 
important,  to  the  intercostal  arteries,  and  to  the  thoracic  and  abdom- 
inal viscera.  The  intercostal  arteries  are  rarely  seriously  injured, 
although  moderate  hsemothorax  is  not  uncommon  after  fracture  of  the 
middle  third,  especially  of  the  sixth  to  the  ninth  ribs.  Fatal  hemor- 
rhage into  the  pleural  cavity  has  occurred  in  a  few  cases,  even  after 
fracture  of  a  single  rib  and  by  slight  violence,  and  a  case  of  traumatic 
aneurysm  has  been  reported  (see  p.  81). 

A  wound  of  the  pleura  and  of  the  lungs  is  a  rather  common  com- 
plication, and  is  generally  caused  by  the  sharp  end  of  a  fragment,  but 
in  some  cases  fatal  injury  of  the  lung  has  been  caused  by  the  crushing 
effect  of  the  external  violence  acting  through  the,  perhaps  unbroken, 
ribs;  the  thorax  is  compressed  by  the  force,  and  the  lung  is  put  upon 
the  stretch  in  such  a  manner  that  it  is  actually  torn,  not  perforated  by 
the  bone.  The  consequences  of  the  wound  vary  with  its  size  and  with 
the  relations  existing  between  the  lung  and  the  thoracic  wall.  If  these 
latter  are  normal — that  is,  if  the  lung  is  not  adherent  at  the  wounded 
part — air  and  blood  escape  more  or  less  freely  into  the  pleural  cavity, 
and  the  lung  collapses ;  if,  on  the  other  hand,  the  lung  is  adherent, 
the  escaping  air  makes  its  way  into  the  meshes  of  the  connective  tis- 
sue, and  may  spread  through  the  mediastinum,  under  the  pericardium 
and  pleura,  and  into  the  interlobular  tissue  of  the  lung  itself  and  the 
sub(!utaneous  tissue  on  the  surface  of  the  body.  Emphysema  of  the 
surface  may  be  produced  also  when  the  lung  is  not  adherent ;  the  air 
which  has  escaped  into  and  filled  the  pleural  cavity  is  forced  by  the 
contraction  of  the  chest  during  expiration  out  through  the  opening  at 
the  fracture,  and  its  place  is  supplied  at  the  next  inspiration  by  fresh 
air  drawn  in  through  the  wound  of  the  lung,  and  thus  a  small  quan- 
tity is  pumped  into  the  outer  cellular  tissue  at  each  respiration,  and 
this  will  continue  until  one  or  the  other  opening  is  closed  by  a  clot  or 
exudate  or  a  change  in  the  relations  of  its  walls. 

Wounds  of  the  heart  are  much  rarer,  and  even  more  dangerous. 
Gurlt  collected  six  cases,  in  only  four  of  which  the  wound  of  the  heart 
appears  to  have  been  caused  by  the  broken  rib ;  in  the  other  two  it 
appears  to  have  been  caused  by  the  compression  of  the  heart  between 
the  anterior  chest-wall  and  the  vertebral  column,  for  the  pericardium 
was  untorn. 

Etiology,  Fractures  of  the  ribs  may  be  caused  by  muscular  action 
or  by  external  violence.  Of  muscular  action  the  most  common  form 
by  far  is  coughing;  others  are  sneezing,  lifting  a  heavy  object,  even 
turning  in  bed.  The  lower  ribs,  especially  the  eleventh,  are  the  ones 
most  frequently  broken  in  this  way,  but  it  has  happened  to  the  second, 
fourth,  fifth,  and  sixth.  It  is  much  more  common  on  the  left  than  on 
the  right  side.     (See  forty  cases  collected  by  Tunis  in  University  Med- 


FRACTURES  OF  THE  RIBS  AND   THEIR  CARTILAGES.        207 

ical  Magazine,  November,  1890,  aud  tliirteeu  personal  cases  by  Cliel- 
mouski  in  Centralbl.  f.  Chir.,  1901,  p.  1188.)  The  so-called  sponta- 
neous fractures  are  observed  almost  exclusively  in  the  insane,  whose 
bones  are  frequently  very  soft. 

By  far  the  most  common  cause  of  fracture  is  external  violence,  bv 
a  blow,  fall,  or  excessive  pressure.  The  fracture  may  be  direct  or 
indirect,  but  it  is  not  often  easy  to  distinguish  between  these  two 
v'arieties.  In  indirect  fractures  caused  by  pressure  upon  or  near  the 
sternal  ends  of  the  ribs  the  fracture  is  found  most  frequently  in  either  the 
anterior  or  the  posterior  third,  and  the  point  of  greatest  frequency  seems  to 
be  very  near  that  at  which  the  force  is  received,  an  inch  or  two  on  the 
outer  side  of  the  sternal  end  of  the  bone.  Double  or  triple  fractures  of 
one  or  more  adjoining  ribs  may  apparently  be  caused  in  either  of  two 
ways  :  Extreme  violence  acting  at  one  point  breaks  the  rib  at  that  point 
by  direct  pressure,  aud  then  depressing  the  broken  ends  breaks  the  bone 
again  at  a  distance  indirectly  on  one  or  both  sides ;  or,  the  force  acting 
more  broadly,  breaks  the  bone  simultaneously  at  a  point  on  each  side. 

Symptoms.  The  symptoms  of  fracture  of  a  rib  in  the  less  severe 
cases  are  likely  to  be  obscure.  The  breathing  is  shallow  and  some- 
times catching  through  pain  or  fear  of  pain,  and  occasionally  there  is 
very  troublesome  reflex  cough.  Pain  is  provoked  by  pressure,  inspi- 
ration, coughing,  sneezing,  and  certain  movements  of  the  body ;  its 
diagnostic  value  comes  from  its  limitation  to  one  point  under  the  dif- 
ferent causes  and  especially  when  pressure  is  made  on  the  affected  rib 
at  a  distance. 

Abnormal  mobility  is  sometimes  present,  but  the  elasticity  and 
mobility  of  the  ribs  make  its  recognition  uncertain.  It  may  sometimes 
be  made  out  by  placing  a  finger  on  each  side  of  the  suspected  fracture, 
and  pressing  alternately  with  one  and  the  other.  The  same  manipula- 
tion may  produce  crepitus,  but  usually  this  is  more  readily  recognized 
by  placing  the  hand  flat  upon  the  chest,  and  pressing  slightly  at  dif- 
ferent points,  or  asking  the  patient  to  cough  or  draw  a  long  breath. 
It  may  also  be  heard  sometimes  on  auscultation  of  the  chest  in  the 
usual  manner,  and  may  be  accompanied  after  a  day  or  two  by  a  })leu- 
ritic  friction  sound,  the  result  of  a  pleurisy  excited  by  the  trauma- 
tism, and  usually  limited  in  area  to  its  immediate  neighborhood.  It 
is  not  uncommon  for  the  patient  himself  to  recognize  the  cre])itus. 
Emphysema  is,  in  itself,  a  very  positive  sign  of  injury  to  the  lung  and 
of  fracture  of  a  rib  if  there  is  no  penetrating  wound  to  account  for  it 
otherwise.  Pneumothorax,  or  hemorrhage  into  the  pleural  cavity  from 
a  lacerated  lung  or  an  intercostal  artery  may  be  present  in  any  of  the 
severer  cases  ;  and  bloody  expectoration,  which  also  points  toward 
fracture,  is  often  present  even  in  slight  cases,  and  is  not  infrequently 
absent  in  grave  ones. 

The  symptoms  of  partial  fracture  or  infraction  are  seldom  definite 
enough  to  permit  a  positive  diagnosis. 

The  course  of  a  simple  uncom])licated  fracture  is  usually  quite 
uneventful;  the  patient  remains  quiet,  sometimes  kee])ing  his  bed,  and 
breathes  carefully  and  suj)erficially  to  avoid  pain;  after  two  or  three 
weeks  he  finds  these  precautious  unnecessary,  and  the  surgeon  finds  on 
examination  that  the  local   tciKlcnicss  has  (lisa])])('ared,  and  that  crep- 


FRACTURES. 


Fig.  96. 


itiis  and  mobility  can  no  longer  be  detected.  Union  by  a  bony  callus 
takes  place  almost  invariably,  notwithstanding  the  defective  immobili- 
zation of  the  parts,  but,  as  a  consequence  of  the  latter,  the  callus  is 
likely  to  be  large,  and,  when  two  or  more  ribs  have  been  broken,  to 
unite  the  adjoining  ones  by  a  bridge  of  new  formation.  Solidity  is 
given  at  first  by  an  ensheathing  callus,  and  the  union  between  the 
fractured  surfaces,  even  when  they  are  in  apposition,  may  remain 
fibrous  for  several  months.     Failure  of  union  is  rare. 

Displacement  upward  or  downward  of  a  fragment  may  lead  to  its 
union  with  the  adjoining  rib,  or  to  the  formation  of  a  lateral  joint 
between  them,  as  in  the  next  following  case ;  or,  if  adjoining  ribs  are 
displaced  in  opposite  directions,  a  gap  may  be  left  between  them  which 
may  lead  to  hernia  of  the  lung,  as  in  a  case  which  is  recorded  in  the 
Gazette  Medicale  de  Paris,  1832,  p.  465,  and  pictured  in  Cruveilhier's 
Atlas  d'Anatomie  Pcdhologique,  a  gap  in  the  right  side  in  front  between 
the  first  and  fourth  ribs,  four  inches  long  and  two  inches  wide.     The 

patient  had  survived   the  accident  about 
forty  years. 

The  course  and  symptoms  in  the  severer 
cases  vary  with  the  degree  and  character 
of  the  complications  which  give  them 
their  gravity.  Emphysema  may  be  slight 
and  transitory,  or  it  may  continue  for  days 
and  spread  over  a  large  portion  of  the 
surface  of  the  body.  If  the  air  escapes 
into  the  cavity  of  the  chest,  or  if  the  frac- 
ture is  compound  with  a  penetrating 
wound,  the  resultant  dyspnoea  and  oppres- 
sion may  be  extreme,  and  the  physical 
signs  of  pneumothorax  will  be  found  upon 
examination.  If,  in  addition  to  the  escape 
of  air,  there  is  also  free  hemorrhage  into 
the  chest  from  the  torn  lung  or  an  inter- 
costal artery,  the  physical  signs  will  be 
correspondingly  modified.  Extreme  dysp- 
noea, due  to  congestion  of  the  lung  follow- 
ing promptly  upon  the  injury,  is  not  un- 
occasionallv   results    and    leads   to    a   fatal 


Fracture  of  ribs,  with  exces^sive 
callus.    (V.  Beegmann.) 


common,   and    pneumonia 
termination  in  the  old  and  feeble. 

I  have  observed  in  half  a  dozen  cases  of  severe  compression  of  the 
chest  with  fracture  or  dislocation  of  ribs  or,  more  commonly,  costal 
cartilages,  a  peculiar  dusky  discoloration  of  the  skin  of  the  fiice,  neck, 
and  upper  part  of  the  chest,  together  with  marked  subconjunctival  bul- 
bar ecchymosis  nearly  limited  to  the  interpalpebral  space.  The  dis- 
coloration does  not  disappear  on  pressure  and  is  apparently  due  to  the 
coloring-matter  of  the  blood,  possibly  through  innumerable  minute 
capillary  extravasations.  It  appears  immediately,  is  evidently  due  to 
the  compression  of  the  chest,  and  disappears  slowly.^ 

Legros  Clark  ^  claims  that  serious  functional  derangement,  without 

1  New  York  Medical  Journal,  March  1,  1890. 

2  Clark:  Diagnosis  of  Visceral  Lesions,  p.  213. 


FRACTURES  OF  THE  RIBS  AND   THEIR   CARTILAGES.        200 

organic  lesion  of  the  lung,  may  result  I'roni  contusion  or  concussion  of 
the  chest,  that  it  may  be  transient  or  may  be  followed  by  inflammation, 
local  or  general,  of  the  aU'ected  lung,  and  that  it  is  sometimes  observed 
in  the  lung  on  the  side  opposite  that  which  has  sustained  the  injury. 

Prognosis.  The  prognosis  depends  largely  upon  the  complications. 
Simple  fractures  without  important  complications  do  well,  as  a  rule; 
the  exceptions  are  found  mainly  in  the  old  and  feeble,  whose  lives  may 
be  endangered  by  congestion  of  the  lungs,  pneumonia,  or  pleurisy. 
Cases  complicated  by  wound  of  the  heart  or  pericardium  are  usually 
promptly  fatal.  Wounds  of  the  lungs  are  serious,  but  there  are  many 
instances  of  recovery  even  in  cases  where  the  laceration  of  the  lung 
was  probably  extensive  and  accompanied  a  fracture  that  was  in  itself 
severe. 

Treatment.  The  indications  for  treatment  are  to  reduce  any  displace- 
ment that  threatens  to  produce  a  complication  or  that  causes  pain,  to 
immobilize  the  chest-wall,  and  to  relieve  or  prevent  pulmonary  inflam- 
mation or  congestion. 

Outward  angular  displacemont  may  be  corrected  by  pressure  upon 
the  projecting  angle,  and  inward  angular  displacement  may  sometimes 
be  corrected,  when  the  broken  surfaces  are  still  in  contact  and  the  frac- 
ture is  situated  near  the  middle  of  the  rib,  by  pressing  the  sternum 
backward  and  thus  springing  the  bone  out.  If  the.  fragments  have 
overriden  this  manoeuvre  is  worse  than  useless,  for  it  can  only  increase 
the  displacement.  Relief  may  also  be  obtained  by  making  the  patient 
strain  or  draw  full  deep  breaths.  Ravaton  relieved  the  pain  and  cor- 
rected the  displacement  in  one  case  by  suspending  the  patient  upon  two 
rods  passed  under  his  axillae. 

When  the  displacement  was  greater  and  one  of  the  fragments  was 
pressed  inward  Malgaigne  ingeniously  made  use  of  the  other  to  elevate 
it,  pressing  it  in  until  the  ends  met  and  became  locked  together  by  the 
irregularities  of  their  broken  surfaces  so  that  the  elasticity  of  the  second 
should  serve  to  raise  the  first. 

For  the  elevation  or  removal  of  a  depressed  fragment  by  operation 
a  number  of  methods  have  been  proposed,  but  very  few  instances  are 
known  of  the  use  of  any  of  them.  If  such  elevation  should  seem 
necessary,  and  if  approach  through  an  incision  were  deemed  inadvisable 
because  of  the  risk  of  the  admission  of  air  to  the  pleural  cavity,  the 
old  suggestion  of  raising  the  bone  by  means  of  a  hook  passed  througii 
the  skin  and  behind  the  upper  border  of  the  bone  might  be  used. 

Immobilization  of  the  chest  is  best  effected  by  suri'ounding  it  with 
a  broad,  snugly  drawn  piece  of  adhesive  plaster,  or  with  two  or  three 
narrower  strips.  The  guide  to  the  amount  of  pressure  is  the  comfort 
of  the  patient.  Malgaigne  preferred  a  bandage  three  or  four  inches 
wide  and  long  enough  to  pass  once  and  a  half  around  the  chest,  and 
he  did  not  place  it  lower  than  the  cnsiform  appendix,  l)elieving  it  to 
be  sufficient,  whichever  ribs  miglit  be  broken,  to  restrain  the  move- 
ments of  the  middle  ones.  When  a  circular  bandage  cannot  be  borne 
he  recommends  that  a  long  narrow  strip  of  plaster  should  be  carried 
from  the  anterior  end  of  the  seventh  rib  on  the  right  side,  for  example, 
across  the  front  of  the  chest,  under  the  left  arm  and  across  the  back  to 


210  FRACTURES. 

and  over  the  right  shoulder,  thence  again  across  the  chest  in  front  and 
around  the  left  side  and  back  to  end  at  the  crest  of  the  right  ilium. 
This  immobilizes  the  left  side  of  the  chest  very  effectually  and  leaves 
the  right  side  free.  He  suggests  that  in  addition  the  arm  should  be 
fixed  to  the  side. 

Tlie  presstire  of  a  bandage  is  useful  also  to  prevent  the  spread  of 
emphysema.  This  complication  seldom  requires  any  more  active  treat- 
ment, althotigh  scariiications  have  been  made  or  the  air  drawn  off"  through 
a  trocar.  If  either  method  is  used  the  instrument  should  be  applied 
at  a  distance  from  the  fracture.  The  more  dangerous  variety  of 
emphysema,  that  in  which  the  air  makes  its  Avay  into  the  mediastinum 
and  the  interlobular  tissue  of  the  lung,  is  not  amenable  to  operative 
treatment. 

In  pneumothorax  it  may  be  desirable  to  draw  off  the  air  through  an 
aspirating  needle  or  a  canula  in  order  to  relieve  the  pressure,  and  if 
blood  accumulates  within  the  pleural  cavity  in  quantities  sufficiently 
large  to  endanger  life  by  iuterference  with  the  action  of  the  heart  and 
either  or  botli  lungs,  it  may  become  necessary  to  remove  it  by  aspira- 
tion or  incision,  but  the  indications  should  be  very  plain  before  the 
surgeon  decides  to  interfere  in  this  manner,  since  the  removal  of  the 
blood  and  the  relief  of  pressure  may  only  lead  to  a  return  of  the  bleed- 
ing. Persistent  internal  hemorrhage  can  be  treated  only  by  indirect 
measures,  because  its  source  cannot  be  recognized,  and,  if  recognized, 
prol3ably  could  not  be  reached,  It  has  been  found  usefid  to  constrict 
the  thighs  circularly  at  the  groin  with  rubber  tubing  or  a  roller-bandage 
just  sufficiently  to  arrest  the  venous  current ;  this  withdraws  a  consid- 
erable amount  oi  blood  temporarily  from  circidation  and  acts  as  a 
ve-uesection.     It  sometimes  arrests  bleeding  instantly. 

AYhen  life  is  threatened  by  pulmonary  engorgement  witli  extreme 
dvspncea,  blood  should  be  taken  from  the  arm  immediately  and  freely, 
and  the  bleeding  should  be  repeated  if  the  symptoms  reappear.  The 
older  records  are  full  of  cases  showing  the  benefit  of  this  practice,  and, 
among  modern  surgeons,  Mr.  Bryant  recommends  it  unhesitatingly  and 
forcibly.  He  says :  "Bleed  with  no  sparing  hand.  .  .  .  When  relief 
has  been  obtained  arrest  the  flow  immediately,  as  syncope  can  only 
do  harm,''  then  follow  with  antimony. 

Fractures  of  the  Costal  Cartilages. 

The  first  mention  made  of  this  lesion  appears  to  liave  been  by 
Zwinger  in  1698,  and  it  i^  not  again  referred  to  in  medical  literature 
until  1805,  when  Lobstein,  at  Strasburg.  and  in  1806  Magendie.  at 
Paris,  each  described  it  with  cases.  Additional  oliservations  were  made 
bv  Delpech,  Sir  Astley  Cooper,  and  Yelpt-au.  and  in  1841  Malgaigne^ 
pui)lished  a  paper  upon  the  subject  which,  six  years  afterward,  he 
reproduced  in  part  in  his  book  on  fractures.  Since  then  but  little 
work  has  been  done  upon  the  subject,  most  writers  contenting  them- 
selves with  reproducing  in  substance  ]\[algaigne"s  chapter.  Gurlt  col- 
lected more  th;in   thirty  cases  for  the  cliapter  up<>n  it  in   liis  book  on 

^  Malgaigue :  Bulletius  de  Thcrapeutiijut,-,  1?41,  p.  227 


FRACTURES   OF  THE  RIBS  AND   THEIR   CARTILAGES.        211 

fractures,  aud  Paulet/  who  apjiears  not  to  have  known  of  Gurlt's 
work,  gives  fourteen  cases  which  he  obtained  by  a  partial  searcli  through 
French  periodical  literature,  only  four  of  which  are  mentioned  by 
Gurlt.  Bourneville  ^  (1880j  and  Pozzi  -^  (1888j  raised  the  list  to  seventy- 
nine  cases.     I  have  seen  two  or  three. 

Fractures  occur  much  more  frequently  at  or  near  the  junction  of  the 
cartilage  and  rib  than  at  any  other  point,  and  more  frequently  in  the 
seventh  aud  eighth  ribs  than  in  any  other.  The  fracture  may  be  double, 
and  may  involve  several  cartilages  on  one  side  or  on  both.  All  the 
recorded  fractures  have  been  complete  with  the  exception  of  one  case ; 
tlicy  have  been  perpendicular  to  the  long  axis  of  the  cartilage,  or  very 
slightly  oblique,  and  the  surface  has  always  been  smooth,  without  ser- 
rations or  splinters. 

It  is  probable  that  persons  advanced  in  life  are  more  liable  to  this 
fracture  than  the  young,  because  of  the  calcification  or  ossification  of 
the  cartilages,  but  it  has  occurred  in  young  men  (seventeen  yearsj  and 
even  in  a  child  seven  years  old. 

Displacement  has  Vjeen  absent  in  a  very  few  cases ;  in  most  it  takes 
place  in  the  antero-posterior  direction,  and  in  some  the  fragments  have 
overriden  in  the  direction  of  the  long  axis  of  the  rib.  This  latter 
form,  probably,  is  possible  only  in  the  longer  and  more  curved  ribs,  or 
when  several  adjoining  ones  are  broken.  The  separation  in  either  of 
these  two  directions  may  amount  to  as  much  as  an  inch,  but  is  i-arely 
so  great.  Either  fragment  may  lie  in  front  of  the  other,  although  the 
costal  fragment  projects  more  frequently  than  the  sternal  one ;  the  dis- 
placement, however,  appears  to  depend  entirely  upon  the  direction  of 
the  fracturing  force  and  upon  the  position  occuj)ied  by  the  patient. 

Xo  instance  of  a  compound  fracture  of  a  costal  cartilage  is  on  record, 
and  the  complications  are  less  frequent  and,  as  a  rule,  less  serious  than 
those  accompanying  fractures  of  the  ribs.  In  some  cases  where  the 
violence  has  been  extreme  and  many  cartilages  have  been  broken  fatal 
injury  has  been  done  at  the  same  time  to  the  heart  or  great  vessels,  but 
not  by  the  penetration  of  one  of  the  fragments  ;  the  viscera  are  crushed 
or  torn  by  the  continued  action  of  the  force  after  the  wall  of  the  chest 
has  yielded  under  it. 

Hernia  of  the  lung  has  been  observed  in  three  cases,  one  after  frac- 
ture of  the  third  and  fi)urth  cartilages  and  rupture  of  the  intercostal 
muscles  by  the  fall  of  a  heavy  Aveight,  the  second,  a  double  one,  after 
fracture  or  diastasis  due  to  paroxysms  of  coughing,  and  tlie  third, 
ol)served  bv  Leo-ros  Clark*  after  a  blow  received  from  the  shaft  of  some 
vehicle.  In  this  one  the  cartilage  of  the  second  rib  was  driven  ni, 
creating  a  gap  through  which  a  tumor  as  large  as  the  fist  appeared  at 
each  inspiration  and  disappeared  at  each  expiration,  leaving  a  depres- 
sion capable  of  containing  at  least  two  ounces  of  liquid.  Recovery  in 
three  weeks,  the  gap  persisting  but  "  evidently  occupied  by  some 
plastic  deposit." 

'  Pauli-t :  Diet.  Encyclopediqiie,  First  Series,  vol.  xxi.,  art.  Cotes,  1878. 

■^  Bourneville:  Progres  Med.,  1880.  3  p  ..gj .  xbi^j.^  October  20,  1888. 

*  Legros  Clark  :  Loo.  cit.,  p.  206. 


212 


FRACTURES. 


In  seven  cases  the  fracture  has  been  produced  by  muscular  action, 
either  an  excessive  effort,  as  to  avoid  a  fall  or  to  throw  a  heavy  object, 
or  coughing  or  sneezing.  Thus  Broca  ^  reported  the  case  of  a  porter 
at  the  market  who  having  placed  a  sack  of  peas  upon  his  shoulder 
asked  a  comrade  to  add  another  to  it.  The  latter  threw  the  second  sac 
heavily  upon  him,  and  in  the  effort  to  avoid  a  fall  under  the  weight  he 
fractured  the  cartilages  of  the  sixth,  seventh,  and  eighth  ribs  on  the 
right  side  at  points  seven  or  eight  centimetres  from  the  median  line. 

Fractures  by  external  violence  may  be  direct  or  indirect.  Gurlt, 
thinks  the  indirect  fractures  take  place  at  or  near  the  costo-chondral 
junction,  the  force  acting  upon  the  rib  itself  in  such  manner  as  to  spring 
its  anterior  end  outward,  while  in  the  direct  fractures  the  force  is 
exerted  upon  a  restricted  area  of  the  cartilage  itself,  as  in  a  fall  upon 
the  edge  of  a  tub  or  step,  the  blow  of  a  fist,  the  kick  of  a  horse. 

The  symptoms  are  local  pain  and  deformity.  Crepitus  and  abnormal 
mobility  are  not  often  recognizable,  but  if  displacement  is  present  it  can 
usually  be  made  out  by  following  the  outline  of  the  rib  and  cartilage 
with  the  finger  and  by  observing  that  it  can  be  increased  or  diminished 
by  pressure  upon  one  or  the  other  fragment.  It  may  not  be  easy  in 
some  cases  to  say  whether  the  fracture  involves  the  rib  or  the  cartilage 
and  in  others  whether  it  is  a  fracture  of  the  cartilage  or  a  dislocation 
of  its  sternal  or  costal  end,  but  the  question  has  no  practical  impor- 
tance. 

The  prognosis,  independent  of  complications,  is  favorable,  and  the 
fracture  may  be  expected  to  unite  in  three  or  four  weeks.  Our  knowl- 
edge of  the  mode  of  repair  has  been  obtained  partly  by  experimentation 
and  partly  by  examination  of  specimens.  When  the  fragments  remain 
end  to  end  and  the  fractured  surfaces  are  more  or  less  completely  in  con- 
tact, a  fibrous  band  unites  them,  and  the  union  is  strengthened  by  an 
external  ring  of  spongy  bone.  In  a  specimen  obtained  by  Basserau^ 
and  examined  microscopically  by  Malassez,  and  in  one  reported  by 
Pozzi,^  it  was  found  that  the  central  band  was  partly  cartilaginous, 
and  it  is  asserted  that  in  other  specimens  points  of  ossification  have 
been  found. 


Fig.  97. 


Fig.  98. 


Repair  of  fracture  of  a  costal  cartilage.      (Gurlt.)       Repair  of  fracture  of  a  costal  cartilage. 

When  the  fragments  override,  they  take,  so  far  at  least  as  the  broken 
ends  are  concerned,  little  or  no  part  in  the  repair.  Union  is  accom- 
plished by  an  intermediate  band  which  is  at  first  fibrous  or  cartilaginous 
and  may'  become  bony  (Fig.  97),  or  if  the  fragments  are  in  contact 

1  Broca :  Quoted  by  Paulet,  loc.  cit.,  p.  83.  '-  Basserau  :  Paulet,  loc.  cit.,  p.  88. 

■*  Pozzi :  Loc.  cit. 


FRACTURES  OF   THE  RIBS  AND   THEIR  CARTILAGES.      213 

the  new  bone  forms  on  the  sides  and  the  ends  (Fig.  98),  and  in  both 
cases  it  envelopes  the  pieces  more  or  less  completely  like  a  ring.  This 
ring  originates  apparently  in  the  perichondrium,  and  its  ossification  is 
the  tinal  result  of  the  formative  irritation  created  by  the  traumatism, 
and  is  analogous  to  the  ossification  seen  so  constantly  not  only  in  carti- 
lage which  would  normally  be  transformed  into  bone,  but  also  in  others, 
such  as  that  of  the  larynx,  whose  normal  evolution  does  not  include 
that  change. 

Treatment.  The  treatment  is  similar  to  that  of  fracture  of  the  ribs  : 
reduction  of  a  displacement  if  necessary  and  possible,  and  immobiliza- 
tion. The  former  must  be  accomplished,  if  at  all,  by  placing  the 
patient  upon  the  opposite  side  or  upon  his  back,  by  drawing  the  shoul- 
ders back,  or  by  deep  inspirations  ;  the  latter  by  a  body  bandage,  strips 
of  adhesive  plaster,  or,  following  Malgaigne's  example,  by  a  hernial 
truss  so  placed  as  to  restrain  the  fragment  that  tends  to  project. 


CHAPTEK  XVII. 

FEACTUEES  OF  THE  CLAVICLE. 

Fracture  of  the  clavicle  is  a  common  injury  and  is  especially 
frequent  in  childhood,  taking  the  place  at  that  age,  as  was  pointed  out 
by  Kronlein,  of  dislocation  of  the  shoulder  by  direct  violence  later  in 
life.  That  is,  a  fall  upon  the  shoulder  breaks  the  clavicle  of  a  child 
but  dislocates  the  shoulder  of  an  adult. 

Pathology. 

It  has  been  found  convenient  by  most  modern  authors  for  the  pur- 
poses of  study  and  description  to  divide  the  fractures  into  three  groups, 
according  as  they  occupy  the  inner,  middle,  or  outer  third  of  the  bone. 
The  average  length  of  the  clavicle  is  six  inches,  and  this  division  into 
thirds  of  about  two  inches  each  corresponds  to  anatomical  differences 
of  considerable  clinical  importance.  To  the  flattened  outer  third  are 
attached  the  trapezius  and  deltoid  muscles  and  the  strong  coraco-clavic- 
ular  ligament  binding  it  to  the  coraeoid  process,  the  inner  fasciculus  of 
which,  known  as  the  coraeoid  ligament,  marks  the  inner  limit  of  this 
portion,  and  can  sometimes  be  readily  felt  upon  the  living  body.  TPie 
dividing  line  between  the  inner  and  middle  thirds  is  not  so  definitely 
marked  anatomically,  it  corresponds  approximately  to  the  point  where 
the  clavicle  crosses  the  lower  or  outer  edge  of  the  first  rib.  The  inner 
third  is  attached  to  the  sternum  by  the  sterno-clavicular  ligaments,  and 
to  the  cartilage  of  the  first  rib  by  the  costo-clavicular  or  rhomboid 
ligament.  To  its  upper  border  is  attached  the  sterno-cleido-mastoid 
muscle,  to  its  lower  the  pectoralis  major. 

Since  the  outer  third  is  broadly  attached  by  ligaments  to  the  scapula 
it  is  apparent  that  after  fracture  of  the  bone  in  the  inner  or  middle 
third  the  outer  fragment  will  not  be  able  to  change  its  relations  to  the 
scapula  materially,  and  that  its  displacement,  therefore,  will  be  gov- 
erned by  the  change  of  position  of  the  latter,  by  its  sinking  inward 
and  forward  to  the  side  of  the  chest  in  consequence  of  the  loss  of  its 
anterior  support. 

The  outer  portion  of  the  middle  third  is  by  far  the  most  common 
seat  of  fractures  observed  clinically,  but  Lane's^  observations  in  the 
dissecting-room  and  his  experiments  indicate  that  fractures  of  the  outer 
third  may  be  very  frequent  and  usually  unrecognized. 

The  fracture  may  be  partial  or  complete,  single  or  multiple,  simple 
or  compound  ;  the  most  frequent  form  is  simple  complete  fracture. 
Compound  fracture  is  so  rare  that  Gurlt  says  he  could  find  only  four 
examples  of  it,  and  Hamilton,  who  gives  the  same  four  cases,  says  he 
had  never  met  with  an  example.     I  have  seen  one  :  A  laborer  was 

^  Lane:  Guy's  Hospital  Eepovts,  1886,  vol.  xliii, 
(214) 


FRACTURES  OF  THE  CLAVICLE. 


215 


struck  ])v  a  falling  stone  upon  the  shoulder  and  sustained  a  fracture  of 
the  right  clavicle  at  a  point  nearly  two  inches  from  the  sternal  end  of 
the  bone.  The  line  of  fracture  was  oblique  from  above  downward  and 
inward.  A  large  ragged  wound  extended  backward  across  the  clavicle 
and  shoulder,  in  which  some  of  the  divided  fibres  of  the  trapezius  could 
be  seen.  The  outer  end  of  the  inner  fragment  was  directed  sharply- 
upward,  the  outer  fragment  lying  below  and  a  little  distance  from  it. 
The  wound  healed  almost  entirely  in  about  six  weeks,  but  when  last 
seen  there  was  still  a  sinus  over  the  end  of  the  inner  fragment  through 
which  a  probe  could  be  passed  to  the  bone. 

Incomplete  or  partial  fracture  is,  according  to  Hamilton,  who  gave 
much  attention  to  this  variety,  very  common.  He  thinks  that  34 
of  the  157  fractures  of  the  clavicle  recorded  by  him  ^  were  partial 
fractures,  and  says  that  at  least  eleven  of  these  were  immediately  and 
spontaneously  restored  to  their  natural  axes.  The  symptoms  accepted 
for  this  diagnosis  are  the  history  of  a  fall  upon  the  shoulder,  or  at  least 
indirect  violence,  the  youth  of  the  patient,  a  swelling  upon  the  upper 
surface  and  front  or  rear  border  of  the  middle  third  of  the  bone  appear- 
ing within  two  or  three  days  after  the  accident,  possibly  a  change  in 
the  axis  of  the  bone,  and  possibly  ability  to  straighten  it  with  slight 
crepitus. 

1.  Complete  fracture  of  the  middle  third  may  be  ol)liqne  or  transverse, 
the  former  variety  being  found  most  commonly  in  adults,  the  latter  in 
children.  The  line  of  an  oblique  fracture  usually  runs  inward  and 
downward  or  backward,  but  may  take  any  other  direction  and  may  be 
nearly  transverse,  or  extremely  oblique  (Fig.  99),  or  practically  longi- 


FiG.  99. 


Oblique  iraeture  of  the  clavicle. 

tudinal,  as  in  a  case  observed  by  Chassaignac  and  mentioned  by  Polail- 
lon,=^  in  which  the  fracture  ran  from  the  centre  of  the  acromial  end  to  a 
point  just  external  to  the  sterno-clavicular  articulation,  dividing  the 
bone  into  two  longitudinal  halves.  Multiple  and  comminuted  fractures 
are  rare.  When  the  fracture  is  multiple  or  double,  the  intermediate 
fragment  is  likely  to  occupy  a  very  irregular  position. 

The  most  common  displacements  "are  produced  by  the  falling  for- 
ward, downward,  and  inward  of  the  shoulder,  the  consequence  of  the 
loss  of  support  normally  furnished  by  the  clavicle,  and  dc])ond  some- 
what upon  the  direction  of  the  line  of  fracture.  The  commonest  torm 
is  that  in  which  the  sternal  fraL^ment  is  drawn  upward  by  the  sterno- 
cleido-mastoid  muscle  or  pushed  upward  b^'  the  outer  fragment,  Avliich 


1  Hamilton  :   Fractures  and- Dislocations,  (Jtli  ed.,  p.  90. 

2  Polaillon:  Diet.  Encyclopediquc,  art.  Clavicule,  p.  «82. 


15 


216 


FRACTURES. 


is  displaced  iuward  along  the  under  or  anterior  surface  of  the  other 
and  has  at  the  same  time  changed  its  direction  somewhat  by  the  sink- 
ing of  its  acromial  end.  The  shortening  may  be  very  notable,  nearly 
one  third  of  the  entire  length  of  the  bone  in  a  specimen  mentioned  by 
Malgaigne.  Another  form  is  found  where  the  line  of  fracture  is  such 
that  the  fragments  do  not  readily  leave  each  other,  and  the  broken 
ends  are  displaced  together  upward  and  backward  by  the  falling  in 
of  the  shoulders  so  that  the  bone  forms  an  angle  at  the  seat  of  fracture. 
In  some  exceptional  cases  the  outer  fragment  has  lain  upon  the  upper 
or  posterior  surface  of  the  inner  fragment.  Malgaigne^  says  this 
variety  was  mentioned  by  Hippocrates,  and  that  he  himself  saw  one, 
but  only  one,  example  of  it.  Under  these  circumstances  the  sternal 
fragment  is  held  down  instead  of  being  pushed  up  by  the  other  one, 
and  the  displacement  is  mainly  in  the  direction  of  the  latter,  the  inner 
end  of  which  is  turned  upward,  forming  a  projection  at  the  seat  of 
fracture. 

Fig.  100. 


Fracture  of  the  clavicle.    Union  with  extreme  displacement. 
Fig.  101. 


Fracture  of  the  clavicle. 

In  tr:;:::verse  fractures  the  broken  surfaces  seldom  leave  each  other, 
and  the  only  displacements  possible  are  in  thickness  and  direction,  the 
lateral  and  angular.  The  latter  is  the  one  usually  seen,  the  angle 
being  directed,  for  reasons  that  have  been  already  stated,  upward  and 
backward. 

The  most  common  and  persistent  cause  of  these  displacements  is 
undoubtedly  the  tendency  of  the  scapula  and  shoulder  to  fall  forward 
and  inward  upon  the  chest,  but  it  is  aided  largely  in  the  first  place  by 
the  fracturing  force  which  continues  to  act  after  the  bone  has  yielded 
to  it.  Thus,  in  a  fall  upon  the  shoulder  or  the  outstretched  hand,  the 
clavicle  breaks  by  the  exaggeration  of  its  normal  curves,  and  as  the 
direction  of  the  line  of  fracture  is  usually  downward  and  inward  the 
outer  fragment  is  forced  inward  on  the  under  side  of  the  other  and 
necessarily  turns  the  outer  end  of  the  latter  upward. 

2.  Fracture  of  the  Outer  Third.  This  variety  is  next  in  frequency  to 
the  preceding,  and  may  be  produced  by  direct  or  indirect  violence. 
The  direction  of  the  line  of  fracture  is  more  commonly  transverse  tlian 
1  Malgaigne :  Loc.  cit.,  p.  468. 


FRACTURES  OF  THE  CLAVICLE. 


217 


oblique.      The  degree  of  displacement  varies  greatly  in  different  cases, 
being  very  notable  in  some  and  slight  or  entirely  absent  in  others. 

When  displacement  exists  it  is  usually  an  angular  one,  the  apex  of 
the  angle  being  directed  backward.  In  some  specimens'  bony  union 
has  taken  place  between  the  clavicle  and  the  scapula,  presumably  by 
ossification  of  the  coraco-clavicular  ligament.  It  is  in  the  form  of  a 
prop  extending  from  the  under  side  of  the  clavicle  to  the  base  of  the 
coracoid  process,  and  sometimes  to  the  notch  of  the  scapula,  and 
usually  convex  posteriorly. 

Fig.  102. 


Fracture  of  the  clavicle,  outer  third.    Extreme  angular  displacement.    (R.  W.  Smith.) 


When  the  fracture  is  external  to  the  trapezoid  ligament — that  is, 
when  it  lies  within  the  outer  inch  of  the  bone — angular  displacement  is 
the  rule,  the  outer  fragment  turning  forward  and  inward  until  its  axis 
is  at  right  angles  with  that  of  the  inner  fragment ;  .sometimes  its  broken 
surface  lies  against  the  anterior  border  of  the  inner  one,  and  sometimes 
the  outer  fragment  lies  under  the  inner  one.  Malgaigne  describes  a 
case  in  which,  after  fracture  within  half  an  inch  of  the  articular  sur- 
face, the  inner  fragment  was  elevated  an  inch  above  the  other,  and 
there  was  shortening  of  nearly  half  an  inch  ;  the  appearance,  in  .short, 
was  that  of  a  dislocation  upward  of  the  acromial  end  of  the  clavicle. 

3.  Fracture  of  the  Inner  Third.  The  older  division,  which  was  into 
fractures  of  the  body  and  fractures  of  the  outer  end,  took  no  special 
notice  of  this  variety  which  received  its  first  .separate  description  from 
Malgaigne.  It  is  the  least  common  of  the  three  ;  Delens,^  who  wrote 
the  first  formal  article  upon  the  subject,  collected  twenty-eight  cases,  to 
which  Polaillon  two  years  later  added  three.  I  have  seen  one  cau.sed 
by  a  direct  blow  with  a  baseball.  The  fracture  may  occupy  any  point 
in  the  division,  and  is  more  often  oblique  than  transverse.  It  was 
a.sserted  at  first  that  the  displacement  did  not  occur  if  the  fracture  was 
within  the  region  of  the  attachment  of  the  costo-clavicular  ligament, 
but  the  contrary  has  since  been  proved  ;  displacement  may  take  place 
in  any  direction,  but  the  commonest  one  is  downward  and  forward  of 
the  inner  end  of  the  outer  fragment,  or  of  the  adjoining  ends  of  both 
fragments  if  they  do  not  separate  from  each  other.  Polaillon  attributes 
the  principal   part  in  the  production  of  this  displacement  to  the  action 

1  .'^mith:  Dublin  .Fourn.  Med.  Sci.,  1842,  p.  47S,  and  Fractures  in  the  Vicinity  of  Joints, 
p.  212. 

'■^  Deleiis:  Archives  Generales  de  Med.,  1H7:'),  vol.  i.  p.  529. 


218  FRACTURES. 

of  the  pectoral  and  deltoid  muscles  upon  the  outer  fragment,  and  finds 
support  for  his  opinion  in  the  fact  that  this  displacement  has  always 
been  observed  after  fracture  by  muscular  action  ;  and  as  in  this  variety 
the  fracture  is  usually  near  the  inner  articular  surface,  in  a  region, 
that  is,  where  displacement  after  fracture  by  other  causes  is  slight  or 
absent,  the  argument  is  not  without  weight,  although  the  obliquity  of 
the  line  of  fracture  in  such  cases  as  that  represented  in  Fig.  103  cannot 
be  entirely  foreign  to  the  direction  and  degree  of  the  displacement. 
When  the  fracture  is  transverse  the  lateral  displacement  may  be  slight 
or  entirely  absent  and  the  periosteum  may  remain  untorn.  Longitu- 
dinal fracture  with  comminution  was  seen  in  one  case,  and  Hamilton 
reports  another  in  which  the  line  ran  from  the  articulation  upward  and 
outward  for  one  and  a  half  inches.  The  fragments  overlapped  three- 
fourths  of  an  inch  and  were  firmly  united.  In  two  cases  the  end  of 
the  outer  fragment  lay  underneath  the  inner  one  and  both  were  directed 
upward  and  backward.  The  outer  end  of  the  inner  fragment  is  acted 
upon  more  strongly  by  the  sterno-cleido-mastoid  muscle  than  by  any 
other,  the  effect  of  which  is  to  draw  it  upward,  and  this  effect  is 
increased  by  the  pressure  of  the  outer  fragment  when  that  is  forced  in 
front  of  and  below  the  other,  so  that  whenever  the  two  fractured  sur- 
faces leave  each  other  the  inner  fragment  is  likely  to  incline  upward. 

Fig.  103. 


Fracture  of  the  clavicle,  inner  third.    (Gurlt.) 

Multiple  Fractures.  But  few  cases  are  recorded  in  which  the  bone 
has  been  broken  in  two  or  more  places  ;  in  some  the  fracture  was  by 
direct,  in  others  by  indirect,  violence.  Both  fractures  have  been  found 
in  the  middle  third,  but  more  commonly  they  occupy  different  thirds. 
When  one  fracture  has  been  in  the  acromial,  and  the  other  in  the  inner 
or  middle  third,  the  intermediate  piece  has  not  shown  much  displace- 
ment, and  each  fracture  has  followed  the  usual  course  of  a  single  one ; 
but  when  the  fractures  have  been  within  or  close  to  the  limits  of  the 
middle  third,  the  displacement  has  been  very  notable. 

Complications.  Complications  of  fracture  of  the  clavicle  consist  in 
injuries  to  the  vessels,  nerves,  and  lungs,  and  are  exceedingly  rare, 
excluding  gunshot  wounds  in  which  the  complications  are  produced  by 
the  ball  and  not  by  the  fractured  bone.  Taylor^  reports  a  case  of 
meurism  of  the  subclavian  artery  and  quotes  another  seen  by  Heath. 
Gallois  and  PioUet^  report  a  case  of  arterio-venous  aneurism  (sub- 
clavian artery)  and  collected  three   others.     Dupuytren    speaks  in  a 

1  Taylor  :  Annals  of  Surji.,  1903.  p.  638. 

2  (Gallois  and  Piollet :  Rev.  de  Cbir.,  1901. 


FRACTURES  OF  THE  CLAVICLE.  219 

lecture  of  haviug  seen  two  or  three  cases  of  aneurism  following  fracture 
of  the  clavicle,  and  Jacqnemiev  gives  a  case  observed  by  J^landin,  of 
an  aneurism  of  the  acromial  branch  of  the  acromio-thoracnc  artery  fol- 
lowing fracture  by  direct  violence.  Taylor  ^  reports  a  case  of  aneurism 
of  the  subclavian  caused  by  a  splinter  from  the  fractured  clavicle  and 
quotes  3  others  by  Heath, '^  Boulby,^  and  Twyman.*  Taylor's  recovered 
after  operation.  Meinhold  '"  reports  a  case  of  gradual  interruption  of 
the  current  in  the  subclavian  artery,  becoming  complete  three  and  a 
half  months  after  fracture  in  the  middle  by  direct  violence,  healing  with 
angular  displacement ;  relieved  by  resection  of  the  angle. 

A  few  cases  are  reported  of  injury  to  the  subclavian  or  internal  jug- 
ular vein,  in  some  of  which  the  diagnosis  was  verified  by  autopsy. 
(See  First  Edition  and  Taylor,  above  quoted.) 

In  the  museum  of  St.  George's  Hospital  is  a  specimen  in  which  the 
fractured  end  of  the  bone  was  driven  through  the  internal  jugular  vein. 
A  man^  fifty-nine  years  old  broke  the  right  clavicle  in  the  middle 
third  by  a  fall  upon  the  shoulder.  The  fracture  was  very  oblique  from 
without  inward  and  backward,  and  the  vein  was  torn  completely  across 
by  the  outer  fragment.     The  artery  and  nerves  were  not  injured. 

Sixteen  cases  ^  have  been  reported  in  which  symptoms  indicating 
injury  to  the  brachial  plexus  have  appeared  immediately  or  after  an 
interval.  In  most  of  those  in  which  they  appeared  promptly  the  causa- 
tive violence  was  great  and  the  displacement  of  the  fragments  marked, 
but  in  mine  there  was  no  displacement.  In  one  (Velpeau)  extensive 
subcutaneous  emphysema  showed  injury  to  the  lung,  and  fracture  of  no 
rib  could  be  detected.  In  two  (Earle,  Stimson)  there  was  paralysis  of 
the  scapular  muscles  supplied  by  the  supra-scapular  nerve  which  leaves 
the  plexus  above  the  clavicle.  In  two  (Davis,  Mauclaire)  the  displace- 
ment was  corrected  by  operation  with  relief  of  symptoms,  and  in  one 
(Poirier)  the  arm  was  amputated  because  of  the  pain.  In  seven  cases 
(Hassler,  Sieur,  Delens,  Polaillon,  Lequyer,  Piqu6,  McCosh),  the 
symptoms  appeared  late;  they  were  due  to  excessive  callus  in  the  first- 
named  six  and  to  a  cicatrix  involving  the  plexus  in  the  last;  all  were 
relieved  by  operation;  but  Lequyer's  only  slightly. 

Injury  to  the  lung,  as  evidenced  by  emphysema,  has  been  recorded 
in  five  cases  where  this  symptom  seemed  to  be  demonstrative,  and  in 
two  others  in  which  it  is  much  more  likely  that  the  emphysema  was 
due  to  the  introduction  of  air  through  a  wound  of  the  soft  parts. 

The    first   five    cases    are    those    of  Vigarous,    Velpeau,    Huguier, 

1  Taylor:  Trans.  Royal  Acad,  of  Med.  in  Ireland,  1903,  p.  225. 

2  Heath:  Med.  Chir.  Soc,  vol.  6.3.  »  Boulby:  Path.  Soc.  London,  vol.  42,  p.  79. 
4  Tvvyman:  Lancet,  1890,  vol.  i.,  p.  1.3.52.  ^  Meinhold:  Miinch.  Med.  Woeh.,  1904,No.  17. 
«  Prog.  Med.,  1882,  No.  16. 

'  Desault,  Velpeau,  Earle,  Gibson,  quoted  by  Gurlt,  loc.  cit.,  ii,  pp.  601,  604,  60();  Polail- 
lon, loc.  cit.,  p.  696:  Mercier,  Des  Complications  des  Fractures  de  la  ("lavicule,  ISM; 
Delens,  Arch,  de  Med.,  Aug.,  1881,  p.  170;  Stimson,  N.  Y.  Med.  Journ.,  June  11,  18S7; 
Poirier,  La  Semaine  Med.,  Sept.  2,  1891;  Mauclaire,  ibid.,  Oct.  17,  1894;  Hassler,  Lyon 
Med.,  .January  12,  1896;  Sieur,  Bull.de  la  Soc.  de  Chir.,  vol.25,  p.  503;  Davis,  Annals  of 
Surg.,  Feb.,  1895;  McCo.sh,  Annals  of  Surg.,  1902,  vol.  .35,  p.  110;  Lequyer,  Gaz.  m6d.  de 
Nantes,  1906,  No.  15,  abst.  in  Ztlblatt.  fur  Chir.,  1906,  p.  1016;  Pique,  Soc.  deChir.,  vol. 
35,  p.  535. 


220  FRACTUREB. 

Riible,  and  Mercier.    All  except  the  fourth  are  described  with  all  the 
details  obtainable  in  a  thesis  by  Mercier.^     (See  First  Edition.) 

The  anatomical  demonstration  of  the  immediate  agency  is  lacking 
in  all  these  cases,  but  the  notes  in  all  but  one  show  that  the  surgeons 
were  mindful  of  the  possibility  that  a  fracture  of  a  rib  might  coexist 
and  might  have  been  the  cause  of  the  wound  in  the  lung,  and  that 
they  were  unable  to  detect  such  a  complication.  In  most  of  them, 
too,  mention  is  made  of  the  depression  of  the  outer  fragment,  and  as 
the  relations  of  the  clavicle  to  the  upper  portion  of  the  thoracic  cavity 
are  such  that  it  is  not  difficult  to  admit  the  possibility  of  a  wound  of 
the  apex  of  the  lung  by  the  broken  bone,  I  think  the  clinical  evidence 
may  be  accepted  as  sufficient. 

Etiology. 

The  clavicle  may  be  broken  by  muscular  action,  by  direct  violence, 
or  by  indirect  violence. 

Gurlt  ^  and  Delens'^  collected  and  analyzed  a  number  of  reported 
cases  of  fracture  by  muscular  action.  The  efforts  by  which  the  frac- 
tures were  caused  were  various  :  lifting  a  heavy  weight ;  striking  with 
the  hand,  a  whip,  or  racket ;  making  a  vigorous  effijrt  that  involved 
the  contraction  of  many  muscles,  as  in  I^egros  Clark's  case  of  a  lad 
who,  while  swinging  by  the  feet  from  a  trapeze,  tried  to  raise  himself 
so  as  to  seize  the  bar  with  his  hands :  the  clavicle  broke  in  its  inner 
third  during  the  effort.  It  is  probable  that  the  clavicular  fibres  of 
the  deltoid  and  pectoralis  major  are  the  most  efficient  agents  in  pro- 
ducing this  fracture,  since  their  contraction  tends  to  draw  the  unsup- 
ported central  portion  of  the  clavicle  downward  and  outward  toward 
the  humerus  when  the  arm  is  fixed. 

Closely  allied  to  these  cases  are  those  in  which  the  fracture  has  been 
produced  by  a  blow  or  other  force  acting  at  the  hand  ;  thus,  an  old 
woman  broke  her  clavicle  by  closing  the  door  of  a  wardrobe  forcibly, 
and  a  lunatic  at  Bicetre  broke  his  by  striking  violently  with  a  heavy 
stick  against  some  iron  bars. 

In  a  very  few  of  the  cases  the  fracture  has  been  produced  by  two 
effi)rts,  or  a  blow  and  an  effort,  separated  by  a  longer  or  shorter  inter- 
val ;  the  patient  feels  pain  at  some  point  in  the  clavicle  after  a  fall  or 
a  blow  or  an  effort,  which  persists,  perhaps,  but  is  not  severe  and  does 
not  interfere  with  the  use  of  the  arm ;  and  then  in  a  few  days,  after 
another  violence  or  effort,  the  bone  breaks.  If  the  second  violence 
were  sufficient  in  itself  to  account  for  the  fracture,  the  first  one  might 
be  regarded  as  a  mere  coincidence,  but  it  has  generally  been  less  than 
the  first. 

Direct  fractures  are  produced  by  varied  causes,  and  may  occur  at 
any  part  of  the  bone,  but  most  frequently  in  the  middle  and  outer 
thirds.  The  commonest  form  of  violence  is  a  blow  falling  upon  the 
centre  of  the  bone  in  a  direction  that  is  backward  and  downward. 

1  Mercier:  Des  Complications  des  Fractures  de  la  Clavicule,  TMse  de  Paris,  1881. 

2  Gurlt:  Loo.  cit.  ^  Delens':  Loc.  cit.,  and  Arch.  Gen.,  1875,  vol.  i,  p.  257. 


FRACTURES  OF  THE  CLAVICLE.  221 

Indirect  fractures,  which  constitute  the  great  njajority,  are  most 
frequently  produced  by  a  fall  upon  the  shoulder  or  upon  the  hand  or 
elbow,  the  arm  being  extended  and  the  muscles  rigid.  In  a  few  cases 
the  fracture  has  been  caused  apparently  by  the  sudden  de})ression  of  the 
shoulder,  by  which  the  clavicle  was  bent  over  the  first  rib.  Malgaigne  ' 
reports  one  :  an  incomplete  fracture  at  the  middle  of  the  bone  due  to  the 
slipping  of  a  burden  from  the  shoulder  to  the  arm;  and  Polaillon^ 
another :  a  man  who  held  the  end  of  a  lever  which  was  to  receive  part 
of  the  weight  of  a  heavy  stone,  the  stone  slipped  suddenly  upon  the 
lever  and  drew  the  arm  which  held  it  downward.  The  man  heard  a 
snap  and  felt  pain  in  the  shoulder ;  the  clavicle  was  broken  in  its 
middle  third. 

The  clavicle  has  been  broken  in  a  number  of  cases  during  intra- 
uterine life  by  external  violence,  and  occasionally  by  the  midwife  or 
obstetrician  during  parturition. 

Symptoms  and  Course. 

The  rational  and  physical  signs  common  to  most  fractures  are  found 
in  those  of  the  clavicle.  These  are  the  deformity,  mobility,  and  crepitus, 
the  localized  pain,  and  the  diminution  of  function.  Besides  the 
deformity  due  to  the  displacement  of  the  fragments,  there  is  also  that 
which  is  produced  by  the  falling  inward  of  the  shoulder  and  which  is 
most  apparent  when  viewed  from  behind,  and  with  it  goes  a  very 
noticeable  projection  of  the  posterior  border  and  inferior  angle  of  the 
scapula. 

In  fractures  of  the  middle  third  there  is  usually  displacement  of  such 
a  character  and  extent  that  there  is  no  difficulty  in  recognizing  it  and 
its  cause;  the  fragments  can  be  separately  grasped  and  moved  upon 
each  other.  Crepitus,  however,  is  not  always  produced  by  this  manoeu- 
vre, for  the  broken  surfaces  may  not  be  in  contact,  and  in  order  to  get 
this  symptom  it  may  be  necessary  to  have  the  shoulder  drawn  back- 
ward and  outward,  so  as  to  reduce  the  displacement. 

Localized  pain  on  direct  pressure  or  when  the  shoulder  is  pressed 
inward  is  a  valuable  sign  in  partial  fractures  and  in  fractures  without 
displacement,  and  it  may  be  the  only  one  that  is  present  immediately 
after  the  injury ;  the  appearance  within  a  week  of  a  firm  oval  mass  at 
the  point  where  pain  was  felt  confirms  the  diagnosis  of  fracture. 
Erdman^  has  pointed  out  a  sign  which  maybe  useful  under  similar 
conditions — loss  of  vocal  fremitus  as  felt  by  the  finger  placed  on  the 
outer  portion  of  the  clavicle,  or  diminution  or  loss  of  the  transmission 
of  whispered  voice  sounds  as  received  through  a  stethoscope  at  the  same 
place. 

The  interference  with  function  seems  to  be  largely  the  consequence 
of  the  pain  which  makes  the  patient  unwilling  to  move  the  arm,  rather 
than  of  any  mechanical  defect  produced  by  the  fracture.  The  patient 
can  usually  move  the  arm  quite  freely  backward  and  forward,  but 
cannot  raise  it  or  adduct  it  without  pain,  and  if  asked  to  put  his  hand 

1  Malsaigne:  Loc.  cit.,  p.  463.  ^  Polaillou:  Loc.  cit.,  p.  079. 

3  Erdmaii:  Jour.  Am.  Med.  Assoc,  April  11,  1911,  p.  740. 


222  FRACTURES. 

on  his  head,  wiU  usually  flex  the  forearm,  inclme  the  body,  and  bend 
down  his  head  to  accomplish  it.  The  fracture  and  displacement  are 
not  entirely  without  influence  in  this  limitation  of  the  movements,  but 
they  are  not  wholly  responsible  for  it.  Hurel/  who  profited  by  his 
internat  at  the  hospital  for  convalescents  at  Paris,  to  examine  the  later 
condition  of  patients  with  this  fracture,  found  the  movement  of  cir- 
cumduction of  the  arm  the  last  to  be  regained,  and  that  a  shortening 
of  half  an  inch  or  more  delayed  complete  recovery  considerably  beyond 
the  time  that  was  sufficient  for  it  when  the  shortening  was  less  or 
absent. 

The  patient's  appearance  is  often  quite  characteristic  ;  he  sits  with 
his  body  and  head  inclined  toward  the  injured  side  and  supports  the 
elbow  with  the  other  hand.  The  only  cases  in  which  the  diagnosis  can 
well  remain  in  doubt  after  even  a  brief  examination  are  those  of  incom- 
plete fracture,  and  some  of  fracture  close  to  either  end  of  the  bone 
which  may  be  mistaken  for  dislocation.  On  the  other  hand,  the  crep- 
itus which  is  so  frequently  present  in  dislocation  of  the  acromial  end 
of  the  clavicle,  because  of  the  chipping  of  the  edge  of  the  joint,  may 
lead  to  a  diagnosis  of  fracture.  Either  error  may  be  avoided  if  the 
outline  of  the  bone  can  be  accurately  traced. 

The  progress  of  the  fracture  is  simple  and  is  rarely  disturbed  by 
complications  or  dangers.  Union  is  usually  firm  by  the  end  of  the 
fourth  week,  sometimes  much  earlier,  and  failure  of  union  is  rare. 
Displacement  and  shortening,  however,  are  the  rule ;  only  those  cases, 
apparently,  are  exempt  in  which  the  line  of  fracture  is  transverse 
and  there  is  no  displacement  at  first.  The  amount  of  the  shortening 
may  vary  from  a  fraction  of  an  inch  to  one  and  even  two  inches,  and 
it  may  be  produced  by  angular  displacement,  or  by  overriding,  or  by 
both. 

The  complications  that  may  occur  in  the  course  of  the  repair  are  the 
ordinary  inflammatory  ones  that  may  arise  at  the  seat  of  fracture  in 
consequence  of  the  bruising  of  the  surrounding  parts,  or  of  the  failure 
to  immobilize  the  fragments,  or  special  ones  due  to  the  pressure  of  the 
fragments  or  callus  upon  the  vessels  and  nerves.  (See  above,  Com- 
])licatwns.)  Delens's^  case  is  very  satisfactory.  The  patient  was 
brought  to  the  hospital  January  1,  1881,  with  fracture  of  the  left 
clavicle  and  two  ribs.  The  arm  was  placed  in  a  Mayor's  sling,  and 
union  was  complete  by  the  end  of  the  month.  The  patient  returned 
on  March  19th,  complaining  of  great  loss  of  power  in  the  left  arm; 
examination  showed  marked  overriding  of  the  fragments,  the  outer 
lying  in  front  of  the  inner  one,  with  a  hard,  firm  callus  two  inches 
thick,  atrophy  of  all  the  muscles  of  the  left  arm,  and  passive  conges- 
tion of  the  skin  of  the  hand;  the  pulsations  of  the  left  radial  artery 
were  much  weaker  than  those  of  the  right.  The  posterior  and  lower 
portion  of  the  callus  was  removed  by  operation,  the  pulsations  of  the 
radial  artery  and  the  appearance  of  the  hand  at  once  became  normal, 

1  Hurel:  Les  Fracttires  de  la  Clavicule,  Th^se  de  Paris,  1867. 

2  Delens:  De  la  resection  d'un  cal  de  la  Clavicule  coniprimant  les  vaisseaux  et  les  nerfs 
sousclaviers,  in  Archives  de  Medicine,  August,  1881,  p.  170. 


FRACTURES  OF   THE  CLAVICLE.  223 

and  the  patient  gradually  recovered  the  use  of  the  limb.  JNIcCosh' 
briefly  reports  a  case  relieved  by  dissecting  the  plexus  out  of  a  mass 
of  cicatricial  tissue  apparently  caused  by  fracture. 

Ossification  of  the  coraco-clavicular  ligament  has  been  observed  in 
several  cases  after  fracture  in  the  outer  third.  No  description  is  given 
of  the  modifications,  if  any,  of  the  functions  of  the  part  produced  by 
this  anchylosis.  Failure  of  union  is  rare,  and  in  the  few  cases 
which  have  been  recorded  it  does  not  appear  to  have  resulted  in 
any  diminution  of  function. 

Simultaneous  fracture  of  both  clavicles  is  a  relatively  rare  accident. 
In  position,  symptoms,  and  mode  of  production  these  double  fractures 
do  not  differ  materially  from  single  ones.  Sometimes  they  are  pro- 
duced simultaneously  by  lateral  pressure  upon  the  shoulders,  some- 
times successively  by  two  different  blows,  and  once  simultaneously  by 
a  kick  of  a  horse,  each  hoof  breaking  a  clavicle. 

In  three  of  the  six  cases  collected  by  Malgaigne,  union  failed  in 
both  bones,  and  he  has  left  a  very  complete  account  of  the  resultant 
disability  in  one  of  them  which  was  under  his  own  care.  In  the 
others  there  was  apparently  but  little  permanent  interference  with  the 
functions  of  the  arms.  In  none  of  the  recently  reported  cases  has 
failure  of  union  been  noted.  In  recent  cases  there  is  sometimes  con- 
siderable dyspnoea,  which  Hurel  thinks  is  due  to  the  weight  of  the 
arms  and  shoulders  upon  the  thorax,  aided  perhaps  by  the  loss  of 
power  of  the  accessory  muscles  of  respiration,  those  which  pass  from 
the  neck  or  thorax  to  the  clavicle  and  scapula.  This  dyspnoea  is  relieved 
by  the  dorsal  decubitus  if  the  shoulders  rest  upon  a  firm  support. 

Treatment. 

The  indications  for  treatment  are  to  reduce  the  displacement  and 
to  prevent  its  recurrence.      The  means  by  which  they  are  to  be  met 
do  not  differ  materially  in  the  differ- 
ent   fractures,    but   in    describing  Fig.  104. 
them  I  shall  have  mainly  in  mind                     A  s 
fractures  of  the  middle  third.               a--.._       y^^^-'' 

As  has   already    been   said,  the  1^"^^*^^^ 

shoulder  and  outer    fragment   are  \//         -— ^^. 

usually  displaced  inward,  forward,     c /^  ^^^ 

and  downward,  and  the  outer  end  1^  ^^ 

of  the  inner  fragment  is  displaced  //  /— ^ 

upward.  The  force  which  produces  \|  (^  ^^^^ 

the  first  displacement  is  the  weight  ^^  xair 

of   the    shoulder.        It     must    be    re-  Mechanism    of    displaepnient    after    fraeturo 

membered  that  the  shoulder  hangs     soaSil^;''A'?''posiUon"'of''the'  ac'romtoi'" ''afte; 

out    from    the    chest    as    a    sign     ^he  fracture. 

hangs  out  from  the  side  of  a  house; 

the  scapula  and  clavicle  are  two  lateral  supports,  and  the  trai)c/,ius 

muscle  is  a  suspensory  one.     A  glance  at  Fig.  104  shows  how  the 

1  McCosh:  Annnls  of  Surgery,  1002,  vol.  xxxv,  p.  110. 


224  FRACTURES. 

fracture  of  the  clavicle  removes  one  lateral  support,  and  how  the 
weight  of  the  shoulder,  being  no  longer  supported  upon  that  side, 
swings  forward  and  inward  until  a  new  equilibrium  is  found.  This 
movement  of  rotation  carries  the  posterior  portion  of  the  scapula 
away  from  the  back  at  the  same  time  that  it  brings  the  anterior  portion 
nearer  the  front,  and  as  the  upper  part  of  the  chest  is  dome-like  and 
not  simply  cylindrical,  and  as  the  movement,  the  change  of  position, 
takes  place  therefore  in  a  vertical  as  well  as  in  a  horizontal  plane,  the 
shoulder  drops  and  the  inferior  angle  of  the  scapula  rises,  by  compari- 
son at  least,  if  not  actually.  Reduction,  therefore,  is  to  be  accomplished 
by  carrying  the  shoulder  back  to  its  former  position,  and  retention  by 
supplying  the  support  previously  given  by  the  clavicle.  These  indi- 
cations have  been  clearly  understood  since  the  time  of  the  earliest 
writers,  but  it  has  been  found  very  difficult  to  embody  them  in  practice, 
because  there  is  no  means  of  acting  in  the  desired  manner  upon  the 
shoulder  that  does  not  involve  an  amount  of  discomfort  that  patients 
will  not  ordinarily  submit  to.  Moreover,  in  some  cases  surgeons  have 
lost  sight  of  the  fact  that  the  position  of  the  arm  is  a  secondary  one, 
its  importance  being  due  solely  to  its  use  as  a  means  of  acting  upon 
the  outer  end  of  the  scapula,  and  that  it  is  useless  to  press  the  elbow 
upward  unless  the  scapula  is  left  free  to  be  raised  by  that  pressure. 

One  of  the  methods  of  reduction  employed  by  Hippocrates  resembles 
in  principle  very  closely  the  dressing  suggested  by  Velpeau  and  em- 
ployed with  much  success  by  him  and  others.  He  placed  the  hand  of 
the  affected  side  upon  the  opposite  shoulder  and  then  pressed  the  elbow 
forcibly  upward  and  outward.  As  the  arm  lies  thus  across  the  chest 
its  long  axis  is  exactly  in  the  direction  in  which  pressure  should  be 
made  to  overcome  the  usual  displacement.  Another  method  employed 
by  Hippocrates  was  to  place  the  patient  upon  his  back  with  a  small, 
hard  cushion  between  his  shoulders,  and  then  to  press  backward  upon 
the  acromion  or  the  head  of  the  humerus  while  the  elbow  was  pushed 
up  by  an  assistant.  Paul  us  ^gineta  made  extension  by  dratviug  the 
arm  upward  and  outward,  and  counter-extension  by  the  neck  or  other 
arm  (recently  revived  by  Bardenheuer),  and  he  also  recommended  the 
axillary  pad  with  the  elbow  brought  close  to  the  side.  Guy  de  Chauliac 
placed  his  knee  between  the  patient's  shoulders  and  drew  them  back- 
ward. These  methods  are  the  types  of  all  that  have  since  been  used  or 
that  are  now  in  use. 

Reduction,  in  short,  is  to  be  sought  by  carrying  the  shoulder  upward, 
outward,  and  backward,  acting  either  directly  upon  it  or  indirectly 
through  the  elbow,  or  using  the  arm  as  a  lever.  Polaillon  recommends 
strongly  a  method  based  upon  the  latter  principle;  standing  behind  the 
patient  he  passes  the  hand  or  forearm  into  the  axilla,  and  draws  upward 
and  backward  with  it,  while  with  the  other  hand  he  presses  the  elbow 
against  the  side  and  thus  forces  the  shoulder  outward. 

In  transverse  fractures  with  only  angular  displacement  upward 
and  forward  it  is  sometimes  sufficient  to  make  pressure  upon  the 
angle. 

The  physical  obstacles  that  need  to  be  overcome  in  the  treatment  are 


FRACTURES  OF  THE  CLAVICLE.  225 

SO  great  and  the  success  that  has  attended  the  different  methods  has 
often  been  so  moderate  that  the  number  of  plans  that  have  been  pro- 
posed and  employed  is  very  great,  and  the  history  of  the  treatment 
shows  mainly  a  recurrence  of  periods  marked  at  first  by  elaboration 
and  multiplication  of  details  and  precautions  and  then  by  the  abandon- 
ment of  tiiem  all  and  the  substitution  of  something  very  sim])le.  The 
results  obtained  by  the  sim])le  scarf  or  sling  are  often  as  good  as  those 
furnished  by  the  most  elaborate  bandaging,  and  the  discomfort  to  the 
patient  during  treatment  is  much  less. 

The  differences  in  the  methods  depend  in  great  part  upon  the  indi- 
cation which  each  surgeon  has  had  more  particularly  in  mind,  upon  the 
displacement  which  he  sought  to  prevent.  Thus,  in  some,  the  special 
object  of  the  dressing  is  to  maintain  the  shoulder  elevated,  in  others  to 
hold  it  back,  and  in  others  again  to  draw  it  outward.  The  type  of  the 
first  class  is  a  band  passing  under  the  elbow  and  forearm  and  around  the 
neck,  the  forearm  lying  across  the  chest.  That  of  the  second  is  a  pos- 
terior transverse  splint  to  the  ends  of  which  the  shoulders  are  made 
fast,  or  an  anterior  transverse  splint  pressing  the  shoulder  back.  That 
of  the  third  is  the  axillary  pad  used  as  a  fulcrum  to  force  the  shoulder 
out  by  pressing  the  elbow  in. 

When  the  patient  is  sufficiently  desirous  to  avoid  any  visible  irreg- 
ularity in  the  outline  of  the  clavicle  to  bear  the  discomforts  of  a 
prolonged  rest  in  bed  without  change  of  position,  and  when  the  dis- 
placement can  be  reduced,  treatment  in  the  recumbent  position  holds 
out  the  best  prospect  of  recovery  without  deformity.  The  patient  should 
be  placed  upon  his  back  (or  rather  upon  Jier  back,  for  it  is  not  probable 
that  any  one  but  a  lady  whose  social  position  requires  her  neck  to  be 
left  at  times  uncovered  will  submit  to  this  confinement),  upon  a  firm 
mattress  with  the  neck  bent  so  as  to  relax  the  sterno-cleido-mastoid  upon 
the  injured  side,  and  the  elbow  fastened  to  the  side  or  chest  or  raised 
upon  a  cushion  so  that  the  weight  of  the  arm  may  tend  somewhat  to 
force  the  shoulder  upward  and  backward,  anatomically  speaking.  It 
has  been  recommended  also  that  a  firm  narrow  cushion  be  placed  along 
the  spine  between  the  shoulder-blades,  and  Robert  preferred  to  have  the 
patient  lie  not  entirely  flat  upon  the  back,  but  inclined  slightly  toward 
the  uninjured  side.  In  one  case  digital  pressure  was  made  upon  the 
fragments  throughout  the  treatment  to  insure  accurate  coaptation. 
The  position  must  be  kept  practically  unchanged  for  at  least  two,  and 
probably  for  three,  weeks. 

Goutraud  ^  has  modified  this  by  keeping  the  arm  dependent  beside 
the  bed  for  a  week  or  two,  and  claims  excellent  results.  The  position 
is  less  irksome  if  the  forearm  is  kept  flexed  by  attaching  the  wrist 
either  to  the  arm  or  to  the  side  of  the  bed. 

Mayor's  scarf  or  sling  (Fig.  105)  is  made  of  a  square  of  muslin, 
the  diagonal  of  which  is  long  enough  to  extend  easily  around  the  body. 
The  forearm  is  flexed  at  a  right  angle  and  laid  across  the  breast;  the 
cloth,  folded  diagonally,  is  laid  over  it  and  tied  around  the  body  so 
that  its  folded  border  runs  horizontally  around  an  inch  or  tA\'o  above 

1  Goutrand:  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  l',)()7,  vol.  .33,  p.  044. 


226 


FRACTURES. 


the  forearm,  in  front  of  which  the  cloth  hangs  down.  The  free  point 
of  the  triangle  is  then  brought  up  between  the  forearm  and  the  body, 
and  the  two  folds  of  which  it  is  composed  are  secured,  one  on  either 
side  of  the  neck,  by  bands  attached  to  the  scarf  behind  and  brought 
forward  over  the  shoulder;  or  the  forearm  is  placed  between  the  folds 
of  the  triangle,  the  folded  diagonal  of  which  thus  forms  the  lowest  part 
of  the  dressing,  while  its  ends  are  tied  around  the  body  as  before.  The 
folds  that  form  the  third  point  are  tied  together  about  the  neck. 

This  method  is  suitable  for  fractures  without  much  displacement, 
especially  for  those  in  children  with  untorn  periosteum. 


Fig.  105. 


Fig.  106. 


Fracture  of  the  clavicle, 
scarf. 


Mayor's 


Velpeau's  dressing  for  fracture  of  the 
clavicle. 


Velpeau's  dressing  (Fig.  106)  is  more  secure.  It  is  made  with  a 
long  roller-bandage.  The  elbow  is  brought  well  in  front  of  the  chest 
and  the  hand  placed  on  the  opposite  shoulder,  and  the  limb  is  drawn 
snugly  up  toward  the  neck  by  successive  turns  of  the  roller  which, 
beginning  at  the  opposite  axilla,  pass  obliquely  across  the  back,  over 
the  shoulder,  in  front  of  the  arm,  under  the  elbow,  and  back  to  the 
axilla;  after  three  or  four  such  turns  have  been  placed  the  bandage  is 
carried  circularly  around  the  body  covering  in  the  arm  from  below 
upward.  The  turns  should  be  secured  by  stitching  or  by  soaking  in 
dextrine  or  plaster. 

Sayee's  Dressing  (Figs.  107  and  108).  A  very  convenient  and 
popular  dressing  is  the  one  introduced  by  Prof.  Sayre.  It  is  made  of 
two  strips  of  stout  adhesive  plaster,  each  about  three  inches  wide  and 
long  enough  to  go  once  and  a  half  around  the  body ;  one  end  of  the  first 
strap  is  stitched  closely  about  the  arm  just  below  the  axilla,  and  the 
other  carried  around  the  chest  from  behind  forward,  as  shown  in  Fig. 
107.  The  second  strap  is  then  carried  from  the  top  of  the  shoulder  on 
the  uninjured  side  across  the  back,  under  the  elbow,  and  along  the  for- 
arm  to  the  shoulder  again  (Fig.  108).    The  elbow  should  be  drawn  back 


FRACTURES  OF   THE  CLAVICLE. 


227 


while  the  first  strap  is  appHed,  and  well  forward  while  the  second  is. 
The  object  of  the  first  strap  is  to  fix  the  upper  middle  portion  of  the 
arm,  so  that  when  the  elbow  is  brought  forward  by  the  second  one  the 
shoulder  should  be  forced  backward  and  upward.  It  is  a  convenience  to 
the  patient  to  have  the  plaster  carried  past  the  ulnar  side  of  the  hand 
so  as  to  leave  the  latter  uncovered.  The  action  of  the  dressing  is 
simply  to  press  the  shoulder  upward  and  backward,  and  its  principal 
advantage  lies  in  the  solidity  which  the  use  of  the  adhesive  plaster 
gives.  A  thin  pad  of  absorbent  cotton  may  be  placed  in  the  axilla  to 
absorb  perspiration. 


Fig.  107. 


Sayre's  adhesive  plaster  dressing  for  fracture 
of  the  clavicle.    First  piece. 


The  same.    Second  piece. 


The  axillary  pad,  designed  especially  to  prevent  shortening  by 
forcing  the  shoulder  outward,  has  been  in  use  for  many  centuries,  and 
reached  its  highest  development  at  the  hands  of  Desault,  of  whose 
complicated  dressing  it  forms  the  essential  part.  I  believe  that  when- 
ever it  is  large  and  firm  enough  to  accomplish  its  object  it  is  dangerous, 
and  whenever  small  enough  to  be  free  from  danger  it  is  useless. 

The  dressings  which  are  intended  mainly  to  draw  the  shoulder  back- 
ward are  modifications  of  the  figure-of-eight  bandage  and  tlie  posterior 
and  anterior  splints.  The  simple  figure-of-eight  carried  across  the  back 
from  one  shoulder  to  the  other,  either  in  muslin  or  j)laster  of  Paris,  I 
have  found  to  interfere  too  much  with  the  circulation  in  the  arms  if  effi- 
ciently applied.  In  two  cases  of  marked  displacement  which  could  be 
reduced  by  drawing  tiie  shouldcM-s  back,  but  which  recurred  under  the 
usual  dressings,  I  obtained  a  satisfactory  result  by  the  use  of  a  breast- 
plate made  of  crinoline  soaked  in  ]»laster  cream  and  covering  the  front 
of  the  chest  and  shoulders.  The  siioulders  were  held  back  and  reduc- 
tion  maintained  until  the  plaster   had  set,  and  then  the  position  was 


228  FRACTURES. 

maintained  by  a  figure-of-eight  bandage.  The  heavy  ends  of  the 
breast-plate  in  front  of  the  shoulder  prevented  compression  of  the 
axillary  vessels  by  the  l)andage,  and  the  dressing  was  worn  with  com- 
fort for  three  or  four  weeks. 

Mayer  and  Cordua  ^  recommend  that  the  forearm  should  be  fixed 
behind  the  back  and  the  shoulder  held  back  by  a  strip  of  adhesive 
piaster  passing  across  its  front  to  the  back.  Mayer  had  used  it  only  in 
a  case  of  fracture  of  the  outer  third,  but  Cordua  appears  to  have  gen- 
eralized its  use.     He  says  that  patients  soon  adapt  themselves  to  it. 

A  modification  of  the  figure-of-eight  suggested  by  Recamier  amounts 
almost  to  a  posterior  splint.  He  placed  a  large,  hard  square  cushion 
between  the  shoulders  behind  and  carried  a  bandage  from  each  upper 
corner  over  the  shoulder  and  under  the  axilla  back  to  the  lower  corner. 

Posterior  splints  have  been  made  in  the  form  of  a  cross,  against 
the  arms  of  which  the  shoulders  were  drawn  back,  and  as  iron,  wooden, 
and  pasteboard  splints  crossing  the  back  and  extending  usually  beyond 
the  shoulders,  so  that  the  traction  of  the  bandages  by  which  the  shoul- 
ders were  made  fast  should  be  exerted  in  an  outward  direction  as  well 
as  backward. 

Dr.  ]Moorhead^  recommends  for  exceptional  cases  fixation  of  the 
forearm,  arm,  and  chest  in  plaster  of  Paris,  the  arm  being  in  full 
abduction  and  the  shoulder  retracted. 

It  is  apparent  that  while  many  different  dressings  may  give  good 
results  in  certain  cases,  none  can  be  depended  upon  to  do  so  in  all,  and 
that  the  displacement,  the  shortening,  which  is  the  rule  in  the  adult,  is 
the  result  in  some  cases  of  forces  which  cannot  be  effectually  controlled, 
of  the  obliquity  of  the  fracture,  and  not  infrequently  of  the  indocility 
of  the  patient,  who,  finding  himself  incommoded  by  the  dressing,  shifts 
it  slightly,  but  often,  until  he  obtains  ease  at  the  sacrifice  of  the  object 
it  was  applied  to  secure. 

If  the  fracture  is  without  displacement,  especially  the  subperiosteal 
fracture  of  children,  or  if  the  displacement  shows  but  little  tendency 
to  recur  after  reduction,  the  simple  scarf  or  sling  or  Sayre's  dressing 
will  answer  every  purpose. 

If,  on  the  other  hand,  the  tendency  to  displacement  is  great,  the 
choice  of  a  method  of  treatment  will  depend  largely  upon  the  character 
and  wishes  of  the  patient.  If  he  is  indifferent  to  the  deformity  or 
intolerant  of  restraint,  it  is  useless  to  attempt  more  than  a  simple 
dressing ;  but  if  he  is  willing  to  submit  to  the  confinement,  the  fracture 
may  be  treated  by  dorsal  decubitus  and  digital  pressure  with  a  fair 
prospect  of  success,  or  by  the  plaster-of-Paris  breast-plate  and  figure- 
of-eight  bandage,  or  Moorhead's.  Fortunately,  persistence  of  displace- 
ment does  not  necessarily  cause  loss  of  function. 

In  simultaneous  fracture  of  the  tw'o  clavicles,  the  dorsal  position  is 
strongly  to  be  recommended. 

It  is  well  to  place  in  the  axilla  a  pad  of  cotton  ^^Tapped  in  a  com- 

1  Mayer  and  Cordua:  Zentralblatt  fiir  Chir.,  1906,  pp.  1004  and  1200. 

2  Moorhead:  The  Postgraduate,  Nov.  1914,  p.  831. 


FRACTURES  OF   THE  CLAVICLE.  229 

press  to  absorb  the  moisture  and  keep  the  opposing  surfaces  from  con- 
tact with  each  other;  and  for  the  same  reason  a  compress  should  be 
placed  between  the  arm  and  the  body,  where\^er  the  two  would  other- 
wise be  in  contact. 

The  dressing  should  be  worn  for  from  fifteen  to  twenty  days  by 
children,  and  twenty  to  thirty  days  by  adults. 


CHAPTER  XVIII. 


Fig.  109. 


FKACTURES  OF  THE  SCAPULA. 

Fractuees  of  the  scapula  clinically  recognized  are  comparatively 
rare,  about  1  per  cent,  of  all  fractures  according  to  the  best  statistics  at 

our  command,  but  Liane's  ^  observa- 
tions in  the  dissecting-room  indicate 
that  fractures  of  the  acromion  are 
very  common  and  must,  therefore, 
usually  pass  unrecognized.  They 
are  six  times  as  common  in  men  as 
in  women,  and  in  the  great  majority 
of  cases  the  patients  have  been  be- 
tween twenty  and  fifty  years  of  age. 
The  size  and  shape  of  the  bone, 
and  the  presence  of  three  irregular 
and  prominent  apophyses  permit  a 
diversity  of  fractures  differing  so 
greatly  in  their  mode  of  production 
and  symptoms  that  it  becomes 
necessary  to  consider  them  sepa- 
rately. Most  writers  in  the  last 
hundred  years  have  made  from  six  to 
eight  groups  as  follows :  1st,  frac- 
tures of  the  body ;  2d,  fractures  of 
the  inferior  angle  ;  3d,  fractures  of 
the  upper  angle  and  supra-spinous 
fossa  ;  4th,  fractures  of  the  spine  ; 
5th,  fractures  of  the  acromion  ;  6th, 
fractures  of  the  coracoid  process  ; 
7th,  fractures  througli  the  surgical 
neck  ;  8th,  fractures  of  the  glenoid  cavity.  Of  these  varieties  the  1st, 
4th,  and  5th  are  by  far  the  most  common  ;  the  others  are  extremely 
rare. 

1.  Fractures  of  the  Body  of  the  Scapula. 

Fractures  of  the  body  of  the  scapula  are  single  or  multiple.  The 
former  are  confined  to  the  subspinous  fossa,  and  the  direction  of  the 
line  of  fracture  is  transverse  or  oblique.  The  fragments  may  preserve 
their  normal  relations  to  each  other  or  there  may  be  displacement,  the 
lower  fragment  shifting  to  either  side  of  the  upper  one  and  overriding 
for  a  greater  or  less  distance.  This  overriding  is  most  marked  on  the 
axillary  side  and  is  due  apparently   to  contraction  of  the  teres  major 

1  Lane  :  Guy's  Hospital  Reports,  1886,  vol.  xliii.  p.  418. 

( 230  ) 


Fracture  across  body  of  the  scapula,  with 
separation  of  a  long  piece  of  the  spine,  A. 


FRACTURES  OF  Tilt:  SCAI'ULA. 


231 


Fiti.  110. 


and  serratus,  while  the  lateral  di.splacemeut  is  the  result  of  the  t^on- 
tinued  action  of  the  fracturino;  force.  In  some  cases  the  fragments  have 
united  after  transverse  or  oblique  fracture  in  such  a  position  that  they 
touch  or  override  at  one  side  and 
are  separated  at  the  other. 

In  multiple  fractures  the  lesion 
is  extremely  variable,  the  fracture 
may  be  "starred,"  or  comminuted, 
some  of  the  lines  may  be  incom- 
plete, and  the  main  one  may  be  longi- 
tudinal ;  the  only  condition,  appar- 
ently, under  which  longitudinal 
fracture  is  met  with  (Fig.  110). 

The  fracture  may  be  partial,  in 
the  form  of  a  fissure  running  from 
one  border,  or  circumscribed,  a  cen- 
tral piece  being  broken  out. 

The  cause  of  the  fracture  has 
almost  always  been  direct  violence, 
usually  a  blow  or  a  fall  upon  some 
angular  object,  but  in  three  reported 
cases  it  appears  to  have  been  caused 
by  muscular  action,  as  in  similar 
fractures  of  the  inferior  angle  (q.  v.), 
the  line  of  fracture  being  somewhat 

higher  than  in  the  latter.     The  cases  are  those  of  Dobson/  Leidy,'* 
and  Hoover.^ 

The  objective  symptoms  which  may  be  met  with  are  irregularity  in 
outline,  abnormal  mobility,  crepitus,  and  ecchymosis.  The  posterior 
border  and  inferior  angle  of  the  bone  can  be  made  prominent  by  carry- 
ing the  elbow  forward  and  inward,  and  then  if  the  finger  is  passed 
along  it  a  transverse  or  oblique  fracture  with  displacement  will  be  cer- 
tainly recognized.  Abnormal  mobility  and  crepitus  can  be  recognized 
by  grasping  the  inferior  angle  and  moving  it  while  the  u]iper  portion 
is  steadied  by  the  other  hand.  In  multiple  or  partial  fractures  with 
depression  the  adjoining  edge  of  bone  may  be  felt  if  the  patient  is  not 
too  fat  or  muscular.  The  precaution  should  always  be  taken  to  make 
a  comparison  with  the  other  scapula,  and  the  normal  ridges  along  the 
borders  and  at  the  base  of  the  spine  should  be  borne  in  mind.  Ecchy- 
mosis, unless  due  to  the  action  of  the  violence  upon  the  soft  ]iarts, 
seldom  appears  until  after  the  lapse  of  a  few  days. 

Localized  pain  on  pressure  and  on  movement  of  the  arm  is  a  con- 
stant symptom,  and  may  make  it  imjwssible  for  the  patient  to  ex- 
tend his  arm  horizontally  and  directly  forward  becau.se  it  is  so  much  in- 
creased by  the  contraction  of  the  muscles  concerned  in  this  movement. 

The  course  in  the  simpler  cases  ends  in  recovery  in  four  or  five  weeks, 
usually  with  preservation  of  function  even  if  union  has  taken  place 


Multiple    (longitudinal)    fracture    of    the 
scapula. 


16 


1  Dobson  :  Lancet,  November  27,  1886. 

2  Leidy  :  University  Medical  Magazine.  IMairh,  1891. 

3  Hoover  :  Medical  and  Surgical  Reporter,  1893,  p.  848. 


232  FRACTURES. 

with  some  unreduced  displacement.  Multiple  fractures  are  more  dan- 
gerous be(!ause  of  the  greater  probability  of  suppuration  at  or  in  the 
neighborhood  of  the  fracture,  and  of  course  if  the  fracture  is  a  com- 
pound one  the  danger  is  still  greater.  In  a  very  few  instances  there 
has  been  much  disability  due  to  failure  of  union  or  to  union  with  dis- 
placement and  exuberant  callus.  Gurlt  quotes  an  example  of  the 
former  in  which  the  patient  was  unable  to  raise  his  hand  to  the  back 
of  his  neck,  and  one  of  the  latter  in  which  the  disability  was  almost 
complete  and  all  communicated  movements  of  the  arm  and  shoulder 
were  painful. 

Treatment.  In  simple  fracture  without  displacement  no  other  treat- 
ment is  needed  than  immobilization  of  the  arm  and  shoulder  during 
the  length  of  time  necessary  for  consolidation.     If  displacement  exist 


Fig.  111. 


^'-  r" 


/' 


Fracture  of  the  body  of  the  scapula.    (U.  S.  A.  Med.  Museum.) 

it  must  be  corrected,  if  possible,  by  placing  the  arm  and  shoulder  in 
various  positions  and  pressing  upon  the  fragments  with  the  hands 
in  the  directions  indicated  by  the  displacement.  When  the  latter  is 
reduced  as  far  as  possible  the  arm  and  shoulder  must  be  immobilized 
by  binding  the  arm  to  the  side  or  merely  supporting  it  in  a  sliug,  and 
a  broad  strip  of  adhesive  plaster  may  be  laid  across  the  scapula  to  aid 
its  immobilization. 

In  comminuted  fractures  the  principal  indication  is  to  prevent  the 
severe  inflammatory  reaction  which  is  so  likely  to  follow  the  bruising 
and  laceration  produced  at  the  same  time  by  the  extreme  violence  that 
has  caused  the  fracture.  If  the  fracture  is  compound  it  must  be 
explored  through  the  wound  and  treated  in  accordance  with  the  prin- 
ciples elsewhere  laid  down,  and  it  is  prudent  in  such  cases  to  remove 
partly  adherent  fragments  which  could  be  safely  left  after  fracture  of 


FRACTURES  OF  THE  SCAPULA.  233 

other  bones,  whenever  by  such  removal  a  free  outlet  that  would  other- 
wise be  lacking  is  supplied  to  matter  that  may  accumulate  on  the  under 
(costal)  surface  of  the  bone.  In  a  few  cases  of  simple  fracture  pus  has 
formed  and  caused  much  trouble  by  burrowing  down  the  side  of  the 
body,  confirming  the  experience  furnished  by  some  simple  fractures  of 
other  bones,  in  which  pus  has  formed  apparently  in  consequence  of 
imperfect  immobilization. 

2.  Fractures  of  the  Inferior  Angle. 

These  are  included  by  some  writers  in  the  group  of  fractures  of  the 
body  of  the  scapula,  from  which  they  differ  merely  by  the  ])roximity 
of  the  line  of  fracture  to  the  lowest  part  of  the  bone,  but  as  they  pre- 
sent a  more  constant  and  well-defined  displacement  which  cannot  be 
readily  overcome  or  prevented  they  deserve  separate  mention.  The 
recorded  instances  of  separate  fracture  are  not  very  numerous.  Gen- 
soul  reported  one  produced  by  muscular  action  ;  the  patient  saved  iiim- 
self  from  falling  to  the  ground  while  descending  a  sharp  incline,  either 
by  catching  hold  of  some  support  or  by  falling  backward  upon  his 
outstretched  hand ;  the  abstracts  of  the  report  are  not  clear  upon 
this  point.  A  triangular  piece  corresponding  to  the  inferior  angle  was 
detached  from  the  scapula  and  displaced  forward  and  upward,  and  could 
be  moved  independently  and  with  crepitus.  Gensoul  attributed  the 
fracture  to  the  sharp  contraction  of  the  teres  major.  Guinard^  reports 
a  second  case  and  quotes  a  third,^  the  only  one  he  could  find.  He 
adds  a  detailed  study  of  fractures  of  the  body  and  inferior  angle  by 
muscular  action  and  quotes  the  rej)orts  of  all  the  known  cases.  The 
histories  of  these  cases  and  of  those  of  fracture  of  the  body  suggest  the 
possibility,  even  the  probability,  that  muscular  contraction  was  the 
cause  in  many  others  in  which  the  history  of  a  fall  upon  the  back  led 
to  the  easy  assumption  of  fracture  by  direct  violence. 

Symptoms.  The  symptoms  are  clear  and  unmistakable :  displace- 
ment of  the  fragment  forward  and  upward  by  the  combined  action  of 
the  serratus  magnus  and  teres  major;  abnormal  mobility  recognized  by 
grasping  the  fragment  with  one  hand  and  moving  it,  or  by  fixing  it 
with  one  hand  and  moving  the  scapula  with  the  other ;  and  crepitus. 
In  one  case^  the  displacement  was  said  to  have  been  downward. 

The  displacement  is  difficult  to  maintain  reduced,  because  the  small- 
ness  of  the  fragment  prevents  efficient  control  of  it,  and  the  tonicity  of 
tiie  muscles  tends  constantly  to  draw  it  away  ;  but  while  this  ensures 
some  deformity  it  is  slight  and  does  not  add  seriousness  to  the  prognosis. 

3.  Fractures  of  the  Upper  Angle. 

These  are  very  rare.  Gurlt  gives  a  figure  of  a  specimen  preserved 
in  Dresden,  and  Hamilton  of  one  in  Philadelphia.  In  the  latter  a 
fissure  extends  well  into  the  subspinous  fossa.  In  both  repair  has 
taken   place   without    much   displacement.       Gurlt   records   two  cases 

^  Guinard  :  Archives  generales  do  Med.,  April,  1890. 

^Sabatier:   Union   Medicale,  18o7,  p.  397. 

3  Denuce:  Journ.  de  Med.  de  Bordeaux,  1892,  vol.  i.  p.  571. 


234  '  FRACTURES. 

observed  during  life ;  in  each  the  injury  was  the  result  of  a  fall  upon 
the  back ;  in  one  there  was  no  displacement,  in  the  other  the  fragment 
was  drawn  upward  and  inward  by  the  levator  anguli  scapulae.  Texier  ^ 
reports  a  case  ;  the  cause  was  direct  violence  ;  prompt  recovery. 

Treatment.  The  treatment  is  to  immobilize  the  arm  and  shoulder  in 
the  position  that  is  most  comfortable,  securing  the  scapula  with  a  body 
bandage  or  strips  of  adhesive  plaster,  and  the  arm  by  binding  it  to  the 
body  with  the  forearm  flexed  across  the  chest, 

4.  Fractures  of  the  Spine  of  the  Scapula. 

There  are  no  known  specimens  of  isolated  fracture  of  the  spine  of 
the  scapula,  and  our  only  knowledge  of  them  is  clinical.  In  those 
I  have  seen  the  diagnosis  was  readily  made  by  recognition  of  the 
abnormal  mobility,  with  crepitus,  of  the  fragment,  and  sometimes  of  an 
irregularity  in  the  outline  of  the  spine. 

Treatment.  The  treatment  is  as  before  ;  immobilization  of  the  arm 
in  a  suitable  position,  and  local  antiphlogistic  remedies  if  required. 

5.  Fracture  of  the  Acromion. 

The  alleged  frequency  of  this  fracture  has  been  called  in  question  by 
those  who  deem  most  of  the  museum  specimens  examples  either  of 
a  traumatic  separation  of  the  epiphysis  or  of  non-ossification.  The 
former  would  still  belong  luider  the  head  of  fractures,  and,  even  if  we 
exclude  the  others,  there  are  still  clinical  instances  in  sufficient  number 
to  make  the  lesion  one  of  the  most  common. 

The  acromion  is  exposed  to  fracture  by  blows  received  directly  upon 
it,  and  also  through  the  humerus,  as  in  a  fall  upon  the  elbow,  and  occa- 
sionally by  muscular  action.  The  line  of  fracture  is  usually  perpen- 
dicular to  the  axis  of  the  apophysis,  but  is  sometimes  oblique.  It  lies 
most  frequently  either  in  front  of  the  acromio-clavicular  joint  or  at 
the  root  of  the  acromion,  rarely  at  an  intermediate  point. 

The  symptoms  are  those  of  fracture,  and  of  the  contusion  if  the 
agency  has  been  direct  violence ;  and  as  the  latter  are  prominent  and 
may  obscure  the  former,  the  fracture  may  be  overlooked.  The  signs 
common  to  both  are  ecchymosis,  local  or  extending  down  the  arm, 
swelling,  and  pain.  The  additional  signs  of  fracture  are  increase  of 
the  local  pain  on  pressure  and  on  moving  the  arm,  usually  complete 
inability  to  abduct  the  arm,  abnormal  mobility,  and  crepitus,  and  pos- 
sibly displacement. 

The  displacement  varies  with  the  position  and  extent  of  the  fracture. 
If  the  latter  involves  only  the  outer  end  of  the  apophysis,  the  displace- 
ment is  slight  and  downward  by  the  contraction  of  the  attached  fibres 
of  the  deltoid,  the  shoulder  loses  a  little  of  its  roundness  in  consequence, 
but  the  head  of  the  humerus  retains  its  place.  If  the  fracture  is  near 
the  base  of  the  apophysis,  the  weight  of  the  arm  tends  to  draw  the 
fragment  downAvard  and  inward,  turning  it  upon  the  outer  end  of  the 
clavicle  as  a  centre,  and  the  shoulder  is  flattened.  The  finger  passed 
along  the  spine  recognizes  an  irregularity  in  the  outline,  usually  a 

'  Texier :  Journ.  de  Med.  de  Bordeaux,  April  5,  1896. 


FRACTURES  OF  THE  SCAPULA.  235 

depression  of  the  outer  fragment,  but  sometimes  an  elevation  or  a 
transverse  groove  or  gap  in  which  tlic  end  of  the  finger  can  rest. 

Crepitus  can  often  be  got  by  hfting  the  elbow  directly  npward,  so 
as  to  push  up  the  acromion,  or  by  abducting  the  arm  ;  and  abnormal 
mobility  must  be  sought  by  varied  manipulations  of  the  apophysis  and 
by  moving  the  arm. 

The  commonest  functional  disturbance  is  the  inability  to  raise  the 
arm,  although  this  is  not  a  constant  symptom,  M'hile  the  power  of  rota- 
tion is  preserved  unaltered,  even  if  somewhat  painful. 

Bony  union  appears  to  be  the  exception,  the  fragments  uniting  by  a 
fibrous  bond  of  greater  or  less  length  and  solidity ;  the  rupture  or  the 
preservation  of  the  periosteum  must  be  of  almost  controlling  impor- 
tance in  determining  the  character  of  the  union.  Ajiparently,  bony 
union  takes  place  only  Avhen  the  fragments  remain  in  close  contact. 
In  one  case  the  distal  fragment  became  necrosed  and  was  cast  out. 

Treatment.  The  treatment  consists  in  reduction  of  the  displacement 
by  pressing  the  head  of  the  humerus  upward  against  the  acromion, 
and  in  securing  it  in  this  position  by  a  bandage  passing  about  the 
body  and  the  arm.  The  dressing  should  be  worn  for  about  three 
weeks. 

6.  Fracture  of  the  Coracoid  Process. 

This  may  be  caused  by  muscular  action  or  by  direct  or  indirect  vio- 
lence ;  in  the  former  the  causative  effort  is  sometimes  comparatively 
slight — w^ringing  wet  clothes  in  one  case — but  more  often  is  a  powerful 
effort  made  with  the  arm.  In  fractures  by  direct  violence  other  bones 
— ribs,  arm,  clavicle — are  usually  coincidently  broken  ;  those  by  indi- 
rect violence  appear,  according  to  the  observations  of  Lane,^  to  be  most 
commonly  produced  by  pressure  of  the  tip  of  the  process  against  the 
clavicle  in  forced  flexion  of  the  shoulder ;  other  instances  are  those  in 
which  the  fracture  is  produced  by  the  impact  of  the  dislocated  head 
of  the  humerus. 

The  line  of  fracture  is  usually  about  an  inch  behind  the  apex  of  the 
process,  but  sometimes  is  further  back,  passing  close  to  the  upper  edge 
of  the  glenoid  cavity  in  a  line  that  corresponds  so  nearly  to  the  position 
of  the  epiphyseal  cartilage  that  some  observers  consider  some  specimens 
to  be  examples  of  separation  of  the  epiphysis,  or  even  simply  of  delay 
in  ossification.  Normally  this  conjugal  cartilage  ossifies  at  about  the 
fourteenth  year.  Bennett"  published  a  case  of  separation  of  the  epi- 
physis, verified  by  autopsy,  in  a  child  six  years  old.  In  one  of  Mal- 
gaigne's  and  in  two  of  Gurlt's  cases  the  end  of  the  process  was  also 
split  longitudinally  into  two  pieces,  one  remaining  attached  to  the  ten- 
don of  the  biceps,  the  other  to  that  of  the  pectoralis  minor. 

The  displacement  is  seldom  great,  because  the  fragment  is  prevented 
from  yielding  to  the  action  of  the  attached  muscles  by  the  coraco- 
clavicular  ligament;  still,  in  one  of  the  last-mentioned  cases  the  frag- 

1  Lane:  British  Medical  Jounial,  May  19,  1888. 

2  Bennett:  Dul)liii   Jourii.    Med.   Sciences,  August,   1888. 


236  FRACTURES. 

ments  were  displaced  more  than  half  an  inch  downward.  Petty ^  gives 
a  skiagram  of  a  case  of  fracture  by  muscular  action  showing  fracture 
at  the  middle  with  tilting  downward  and  inward  of  the  distal  portion. 

Fig.  112. 


Fracture  of  the  coracoid  process. 

Symptoms.  The  symptoms  are  abnormal  mobility  and  crepitus,  but 
are  not  easily  recognized,  especially  if  the  soft  parts  be  much  bruised 
and  swollen;  the  depth  at  which  the  process  is  placed,  and  the  thick- 
ness of  the  overlying  muscles,  make  it  difficult  to  grasp  the  process 
between  the  fingers  or  to  appreciate  its  independent  mobility.  I  have 
also  noticed  localized  pain  on  forcible  voluntary  adduction  of  the  arm 
and  flexion  of  the  forearm. 

The  fracture  in  itself  involves  no  danger  to  life,  and  no  probable 
disability,  although  the  union  is  seldom  bony.  Of  six  specimens  exam- 
ined by  Gurlt  bony  union  was  found  in  only  one ;  in  four  cases  men- 
tioned by  him  of  which  our  knowledge  is  only  clinical,  mobility 
persisted  in  two.  This  failure  of  union  does  not  seem  to  cause  any 
loss  of  function.  In  Hulme's  case  the  union  was  firm  but  the  frag- 
ment somewhat  displaced  downward. 

Treatment.  The  treatment  must  be  directed  to  immobilizing  the 
arm  in  a  position  which  will  relax,  as  well  as  may  be,  the  muscles 
attached  to  the  process.  Theoretically,  the  best  position  is  that  in 
which  the  forearm  is  flexed  and  the  elbow  carried  across  the  front  of 
the  chest,  but  this  cannot  be  carried  out  thoroughly  without  causing 
more  discomfort  than  the  benefit  to  be  obtained  by  it  will  warrant ; 
and  it  is  best,  therefore,  simply  to  fix  the  arm  against  the  side  with 
the  forearm  comfortably  flexed. 

Fractures  of  the  Neck  of  the  Scapula. 

Under  this  term  I  include  fractures  which  pass  from  the  supra- 
scapular notch  to  the  axillary  border  of  the  scapula,  those  which  begin 
in  the  fossa  and  pass  obliquely  downward  and  backward  to  the  axillary 
border,  and  Braun's  case  (noted  in  previous  editions  in  the  preceding 
section)  in  which  the  line  passed  from  the  notch  into  the  glenoid  fossa, 
together  with  a  few  variants  of  it  since  reported.    There  is  no  known 

1  Petty:  Annals  of  Surgery,    March,    1907. 


FRACTURES  OF   THE  SCAPULA. 


237 


example  of  fracture  running  close  behind  and  parallel  to  the  glenoid 
fossa  along  what  is  sometimes  termed  the  anatomical  neck. 

The  subject  has  been  thoroughly  studied  by  Hitzrot  and  Boiling 
in  a  valuable  paper  including  seven  personal  cases  and  a  large  bibliog- 
raphy in  the  Annals  of  Surgery,  February,  1916.  Our  knowledge  of 
the  details  and  of  the  association  of  the  symptoms  has  been  much 
aided  by  the  a;-rays. 

The  first-named  form,  that  in  which  the  fracture  passes  from  the 
suprascapular  notch  to  a  point  in  the  axillary  border  not  far  below  the 
glenoid  (Fig.  113)  is  much  the  most  frequent.  To  the  main  line  of 
fracture  are  sometimes  added  others  running  into  or  across  the  body 
of  the  scapula. 

Fig.  113. 


Fracture  of  the  neck  of  the  scapula. 

The  small  anterior  fragment  always  carries  with  it  the  attachment 
of  the  triceps  and  usually  the  entire  coracoid  process;  but  the  liga- 
ments which  bind  the  coracoid  process  to  the  clavicle  and  acromion 
remain  untorn,  as  does  also  a  ligament  extending  from  the  under  surface 
of  the  spine  of  the  scapula  to  the  edge  of  the  glenoid  cavity,  and  they 
limit  displacement  downward.  In  Hitzrot  and  Boiling's  four  cases 
there  was  only  a  slight  displacement  inward. 

The  cause  has  been  a  fall  or  a  blow  upon  the  shoulder;  in  one  case 
slight,  a  fall  from  a  bed,  but  usually  severe. 

Farabeuf  found  that  if  the  anterior  portion  of  the  capsule  was 
made  tense  bv  outward  rotation  of  the  arm  the  neck  could  be  broken 


238  FRACTURES. 

by  a  blo\\'  on  the  back  of  the  head  of  the  humerus  or  by  one  upon 
the  elbow  if  the  arm  was  also  directed  backward. 

The  sjTnptoms  are  slight  flattening  of  the  outer  side  of  the  shoulder 
and  prominence  of  the  acromion;  and  Hitzrot  and  Boiling  note  some 
fulness  of  the  infraclavicular  fossa  and  pain  on  pressure  "over  the 
coracoid  region"  and  on  pressing  the  head  of  the  humerus  inward. 
There  may  also  be  pain  on  pressure  upon  the  border  of  the  scapula 
high  up  in  the  axilla.  A  s\Tiiptom  to  which  much  prominence  was 
given  in  the  earlier  descriptions,  the  falling  of  the  limb  away  from 
the  acromion  and  its  easy  replacement,  has  been  lacking  m  all  the 
later  cases  verified  by  the  .r-rays.  I  saw  a  case  m  a  military  hospital 
in  Remiremont  in  which  this  displacement  was  said  to  have  existed 
and  to  have  been  reducible  only  by  abduction  of  the  arm.  The  habitual 
slight  iuAvarrl  displacement  of  the  fragment  could  not  cause  this  symp- 

FiG.  114. 


Fracture  of  the  neck  of  the  scaptda.     Spence's  case.      CGtrRLX.) 

torn,  and  it  seems  probable  that  its  presence  in  the  earlier  cases  was  due 
to  deltoid  paralysis  or  that  the  cases  were  of  the  second  form,  fracture 
of  the  lower  half  of  the  glenoid  fossa.  The  yellow  stain  of  extravasated 
blood  appears  tardily  in  the  axilla  and  the  infraclavicular  fossa.  Active 
motion  is  impossible;  passive  motion  is  checked  by  pain. 

Immobilization  of  the  arm  by  a  suitable  bandage  has  proved  mii- 
formly  effective  and  the  restoration  of  function  has  been  practically 
complete. 

In  the  second  form  the  line  of  fracture  crosses  the  glenoid  fossa  near 
its  center  and  passes  to  the  axillary  border,  as  sho-^m  in  Figs.  114  and 
115.  Hitzrot  and  Boiling  saw  two  and  collected  three  other  cases 
confirmed  by  autopsy  or  .r-ray.  In  one,  Spence's,  dropping  of  the  limb, 
with  easy  replacement,  was  present ;  in  another  it  appeared  slowly  as  a 
consequence  of  deltoid  paralysis  due  to  mjury  of  the  circumflex  nerve 
and  disappeared  when  that  ended.  The  fragment  in  two  cases  was 
displaced  downward  and  tilted  so  that  its  lower  edge  was  shifted  for- 
ward from  the  body  of  the  bone.  This  suggests  either  that  the  fracture 
was  by  avulsion  (long  head  of  the  triceps)  or  that  the  displacement 
was  caused  later  by  the  pull  of  that  muscle. 


FRACTURES  OF   THE  SCAPULA. 


239 


The  only  positive  symptom  is  recognition,  when  possible,  of  the 
projection  of  the  end  of  the  fragment  high  in  the  axilla;  a  supporting 


Fig.  115. 


Fracture  of  neck  of  scapula. 

Fig.  116. 


Fracture  below  base  of  coracoid.     (Braun.) 


symptom  is  pain  when  the  forearm  is  actively  extended  against  r(>sist- 
•  ance  (pull  of  the  triceps).  Pain  on  pressure  and  on  movement;  active 
and  passive  movements  restricted.    For  an  exact  diagnosis  the  aid  of 


240 


FRACTURES. 


the  a'-rays  is  needed.     Simple  immobilization  of  the  limb  without 
correction  of  the  displacement  has  given  a  good  recovery. 

In  the  third  form  the  fragment  comprises  the  upper  half  of  the  glenoid 
and  the  coracoid  (Fig.  116).  In  the  first  reported  case,  Braun's/  the 
patient  was  struck  by  a  locomotive  and  died  of  associated  injuries. 
Preiser^  says  he  has  seen  several  cases  verified  by  the  a:-rays  and  one 
specimen  from  an  old  case,  that  the  line  of  fracture  may  extend  to  the 
upper  or  to  the  vertebral  border  of  the  scapula.  In  Hitzrot  and  Boiling's 
case  the  injury  was  caused  by  a  fall  from  a  height.  The  injury  is 
evidently  one  that  can  be  recognized  only  by  the  aid  of  the  x-rays. 
In  Hiztrot's  case  immobilization  of  the  arm  gave  recovery  with  limita- 
tion of  motion. 

8.  Fracture  of  the  Glenoid  Cavity. 

In  almost  all  the  instances  that  are  on  record  this  fracture  has  been 
discovered  post  mortem  or  during  operation  after  dislocation  of  the 
shoulder.  It  is  thought  to  be  not  uncommon,  but  as  the  diagnosis  is 
very  difficult  its  frequency  cannot  be  determined.  Usually  the  frac- 
ture is  of  the  inner  border  of  the  articular  surface,  but  sometimes  the 
outer  or  lower  border  has  been  broken  off;  and  Flower  says  that  frac- 
tures have  been  found  running  across  the  glenoid  fossa  and  even  split- 
ting it  into  several  portions.  Poland^  showed  a 
specimen  of  stellate  fracture  of  the  fossa  with 
three  lines  radiating  thence  to  the  body;  there  was 
also  fracture  of  the  acromion,  but  no  dislocation. 
Agnew  gives  a  similar  figm-e,  but  does  not  state 
the  source  from  which  it  was  derived. 

Symptoms.  The  symptoms  cannot  be  described 
because  no  case  appears  to  have  been  recognized 
during  life;  and  it  seems  unlikely  that  a  diagnosis 
could  be  made  with  any  positiveness.  The  frag- 
ment is  small  and  not  accessible  to  direct  man- 
ipulation, so  that  the  only  symptoms  would  be 
those  of  a  dislocation  together  with  crepitus  on 
reduction,  and  perhaps  a  ready  recurrence  of 
the  dislocation — signs  that  may  be  present  under  a  variety  of 
circumstances. 

Treatment.  Treatment  must  be  limited  to  reduction  and  immobili- 
zation, and  the  latter  should  be  more  complete  and  better  guarded  than 
after  a  simple  dislocation,  because  of  the  greater  ease  with  which  the 
head  of  the  humerus  can  escape  from  the  glenoid  cavity  when  the  rim 
of  the  latter  is  broken. 


Fracture  of  edge  of  gle- 
noid fossa.      (V.  Bruns.) 


1  Braun:  Arch,  fur  klin.  Chir.,  vol.  42,  p.  110. 

2  Preiser:  Ztlblatt.   fur  Chir.,    1912,   p.  880. 

3  Poland:  British  Medical  Journal,  January  23,  1892. 


CHAPTER   XIX. 

FRACTURES  OF  THE  HUMERUS. 

The  tables  in  Chapter  I.  sliow  that,  while  fractures  of  the  upper 
extremity  (including  the  clavicle)  constitute  nearly  half  of  all 
fractures,  those  of  the  humerus  are  only  4  per  cent,  of  all,  and  this 
bone  is  less  frequently  broken  than  either  the  clavicle,  radius,  or 
ulna.  Different  tables  of  statistics  show  great  variations  in  the  rela- 
tive frequency  of  the  fractures  of  the  different  portions  of  the  bone, 
some  giving  the  greatest  number  to  the  shaft,  others  to  the  lower  end, 
but  all  agree  in  giving  the  greatest  frequency  to  the  first  twenty  years 
of  life. 

The  different  varieties  of  fracture  may  be  most  conveniently  studied 
by  arranging  them  in  three  groups  :  fractures  of  the  upper  end,  frac- 
tures of  the  shaft,  and  fractures  of  the  lower  end,  although  the  first 
and  third  groups  severally  contain  varieties  which  differ  materially 
from  one  another. 

For  a  remarkable  case  of  longitudinal  fracture  extending  the  entire 
length  of  the  bone  which  cannot  be  placed  in  any  one  of  these  groups, 
the  reader  is  referred  to  page  27. 

1.    FRACTURES    OF    THE    UPPER    END    OF    THE    HUMERUS. 

The  fractures  of  this  region  include  fissures  and  chippings  of  the 
articular  head,  fractures  of  the  tuberosities,  of  the  anatomical  neck,  and 
along  the  epiphyseal  line,  and  a  group  comprising  the  great  majority 
of  fractures  in  this  region  in  which  the  line  of  fracture  crosses  the  bone 
in  a  variety  of  ways  between  the  anatomical  neck  and  the  lower  bor- 
der of  the  surgical  neck,  which  is  commonly  drawn  at  the  insertions 
of  the  teres  major  and  pectoralis,  and  which  includes  fractures  pro- 
duced by  compression,  so-called,  cross-strain,  and  torsion.  Al)ove, 
this  group  unites  with  or  closely  approaches  fractures  of  the  anatomical 
neck,  and  below  with  oblique  and  comminuted  fractures  of  the  adjoin- 
ing portions  of  the  shaft.  Its  upper  limit  may  be  placed  at  those  frac- 
tures which  pass  along  or  very  close  to  the  lower  (inner  and  posterior) 
portion  of  the  anatomical  neck  and  then  reach  the  outer  side  through 
the  greater  tuberosity;  the  lower  limit  may,  for  clinical  reasons,  be 
conveniently  placed  low  enough  to  include  even  quite  oblique  fractures 
in  which  one  end  of  the  line  rises  to  the  surgical  neck.  Between  those 
at  the  upper  limit  and  fractures  of  the  anatomical  neck  are  some  in 
which  the  line  is  doubled  on  the  outer  side — a  fracture  of  the  anatomical 
neck  with  a  second  line  passing  through  the  tuberosities  from  about  the 
middle  of  the  first.     As  these,  like  pure  fractures  of  the  anatomical 

(241) 


242  FRACTURES. 

neck,  are  frequently  associated  with  anterior  dislocation  of  the  shoulder, 
and  as  they  lack  the  clinical  characteristics  of  the  lower  fractures,  I 
shall  describe  them  in  the  same  section  with  fractures  of  the  anatomical 
neck,  but  under  a  separate  title — -fractures  through  the  tuberosities  ;  their 
lower  line  is  the  same  as  that  of  the  highest  of  the  main  group  (frac- 
tures of  the  surgical  neck),  the  distinction  lying  in  the  addition  of  a 
line  along  the  anatomical  neck  detaching  the  head.  The  lower  main 
group  is  characterized  clinically  by  the  fact  that  the  upper  fragment  is 
peculiarly  subject  to  the  unopposed  action  of  the  scapular  muscles ;  a 
separate  class  is  made  of  separation  of  the  epiphysis  in  the  young,  but 
fractures  in  the  adult  which  follow  in  the  main  the  former  line  of  the 
conjugal  cartilage  are  not  separated  from  the  main  group. 

In  this  section,  then,  will  be  considered  fractures  of  the  head,  of  the 
anatomical  neck,  through  the  tuberosities,  of  the  tuberosities,  and  of 
the  surgical  neck,  and  separation  of  the  epiphysis. 

A.  Fractures  of  the  Head. 

Simple  fissures  or  partial  fractures  of  the  head  of  the  humerus  with- 
out associated  fracture  of  the  tuberosities  or  surgical  neck  are  very  rare. 
To  the  two  instances  which  Gurlt  quotes  from  Gosselin  and  Gross  ^ 
may  be  added,  I  think,  three  others,  one  described  by  Malgaigne,"  the 
other  two  by  Houel. 

Houel's  first  case  is  a  specimen  in  the  Musee  Dupuytren  ;  about  one- 
third  of  the  head  of  the  humerus  has  been  broken  oif  and  has  reunited. 

His  second  case,  also  in  the  same  museum,  is  a  specimen  of  fracture 
through  the  head  separating  a  thin  fragment  entirely  covered  with 
articular  cartilage.  The  fragment  was  turned  completely  over  and  not 
united.  The  patient  was  an  old  woman  and  died  seven  or  eight  months 
after  the  receipt  of  the  injury. 

The  cases  are  much  more  numerous  in  which  the  articular  surface  is 
fractured  in  connection  with  fracture  of  adjoining  parts ;  and  in  ante- 
rior dislocation  of  the  shoulder  (q.  v.)  deep  indentation  or  bruising  of 
the  surface  of  the  head  by  the  edge  of  the  glenoid  fossa  is  apparently 
not  infrequent. 

B.  Fracture  of  the  Anatomical  Neck,  and  Fracture  Through  the 

Tuberosities.^ 

Fracture  of  the  anatomical  neck,  without  an  additional  line  of  frac- 
ture through  the  tuberosities,  is  apparently  a  very  rare,  and  also  a  very 
obscure,  injury,  except  in  association  with  anterior  dislocation  of  the 
shoulder.  Although  it  is  described,  and  the  means  of  diagnosis  given, 
in  all  systematic  works  upon  the  subject,  it  must  be  admitted,  I  think, 
that  our  knowledge  of  it  is  extremely  scanty  and  uncertain,  being 
limited  to  a  few  specimens  and  to  a  few  cases  clinically  observed  in 
which  the  diagnosis  remains  more  or  less  doubtful.  The  reported 
specimens  of  fresh  fracture,  without  dislocation  or  additional  fracture 

1  Gross'  Surgery,  fifth  ed.,  vol.  i.  p.  985.  ^  Malgaignc's  Atlas,  Plate  iv.  Fig.  2. 

^  It  is  to  be  noted  that  some  writers  include  both  forms  uuder  the  title  "  Fracture  of  the 
Anatomical  Neck." 


FRACTURES  OF   THE  HUMERUS. 


243 


through  the  tuberosities,  are  those  of  Boyer  ^  and  Speuce  ;^  both  patients 
were  .aged,  and  in  each  tiie  injury  was  caused  by  a  fall  upon  the  shoul- 
der. The  reported  specimens  from  cases  in  which  the  fracture  was 
associated  with  dislocation  are  more  numerous,  but  in  so  many  of  such 
cases  associated  fracture  of  the  tuberosities,  generally  without  displace- 
ment, is  mentioned  that  it  seems  probable  it  may  have  been  overlooked 
or  passed  without  comment  in  many  of  the  others.  These  specimens 
have  been  obtained  in  the  course  of  operations  undertaken  for  the 
removal  of  the  dislocated  head  or  for  the  reduction  of  the  dislocation. 
Usually  the  head  remains  attached  to  the  shaft  by  a  strip  of  perios- 
teum or  capsule,  and  in  three  of  my  own  cases  the  line  of  fracture 
diverged  from  the  neck  and  split  off  a  thin  piece  of  the  shaft  adjoining 
the  lowest  portion  of  the  head. 

The  clinical  cases  are  obscure,  even  uncertain.  A  number  of  sup- 
posed cases  have  recently  been  reported  in  which  the  diagnosis  rested 
upon  skiagraphic  showings,  but  the  skiagrams,  as  published,  leave 
in  mv  mind  much  doubt  of  the  accuracy  of  this  diagnosis  ;  it  seems 
probable  that  the  line  in  fracture  runs  in  part,  at  least,  through 
the  tuberosities.  Kocher^  reports  three  cases  in  which  he  thought 
this  diagnosis  could  be  made.  The  first  was  a  man  seventy-nine 
years  old  who  fell  from  a  height  upon  his  side  ;  the  shoulder  was 
swollen ;  no  deviation  of  the  axis  of  the  arm  ;  shortening  half  a  centi- 
metre ;  active  motion  lost,  passive  motion  gave  distinct  crepitus.  The 
head  projected  in  front  below  the  acromion  and  could  be  drawn 
downward  away  from  it,  so  that  the  finger  could  be  passed  in  beneath 
the  acromion  and  could  there  feel  be- 
hind the  fulness  of  the  head  in  the 
region  of  the  anatomical  neck  the 
edge  of  the  lower  fragment  directed 
backward  In  the  second  case,  also  a 
fall  upon  the  side,  the  patient  was 
nineteen  years  old,  and  the  edge 
could  be  similarly  felt ;  movements 
were  very  painful.  The  third  patient 
was  a  woman  sixty-one  years  old  ;  the 
cause  a  fall  upon  the  front  of  the 
shoulder.  Slight  swelling,  pain,  loss 
of  function,  crepitus  on  rotation  of 
the  arm  ;  displacement  of  the  u])per 
fragment  upward  could  be  felt.  Figs. 
118  and  119  represent  his  conception 
of  the  fracture  and  the  displacements. 

I  have  seen  only  one  case  in  which  the  diagnosis  seemed  ]>robable. 
The  patient,  whom  I  presented  to  the  New  York  Surgical  Society,* 
was  a  man  about  thirty-five  years  old,  who  had  fallen  on  his  back  in 
front  of  a  horse-car  in  such  a  way  that,  as  the  car  passed  over  him,  the 


Fig.  118. 


Fig.  119. 


Supposed  displacement  and  liue  of  frac- 
ture of  anatomical  neck  of  the  humerus. 

(KOCHER.) 


■  Boyer:  Traits  des  Maladies  Chiruri;icales,  1831,  vol.  iii.  p.  199. 
^  Spence  :  Edinburjrh  Medical  Journal,  I80O,  vol.  v.  p.  1140. 
'Kocher:  Praktisch  wichtiger  Frakturformen,  189(i. 
*  Stimson  ;  New  York  Medical  Journal.  March  19,  1891,  p.  .310. 


244 


FRACTURES. 


edge  of  the  front  platform  caught  against  his  right  elbow  and  pressed 
the  humerus  with  great  force  against  the  scapula.  Swelling  and  pain 
at  the  shoulder,  complete  loss  of  function  ;  the  tuberosities  rotated  with 
the  shaft ;  the  acromion,  coracoid,  and  neck  of  the  scapula  were  unin- 
jured; pressing  the  arm  upward  against  the  acromion  gave  pain  and 
was  accompanied  by  crepitus.  He  was  treated  in  the  recumbent  posi- 
tion with  moderate  continuous  traction  for  five  weeks,  and  made  a 
complete  recovery. 

On  another  occasion  I  had  an  opportunity  to  examine  an  undoubted 
case.  The  patient  had  suffered  the  fracture  with  dislocation,  and  I 
was  able  clearly  to  recognize  the  small,  movable  upper  fragment  in  the 
axilla.  Under  anaesthesia  I  was,  fortunately,  able  to  reduce  the  dis- 
location, and  then,  being  in  presence  of  a  fracture  of  the  anatomical 
neck  without  dislocation,  I  examined  it  carefully  in  order  to  ascertain, 
if  possible,  a  means  of  diagnosis ;  but  I  could  detect  nothing  abnormal, 
no  deformity,  no  crepitus ;  after  the  anaesthesia  had  ended,  pressure 
upward  at  the  elbow  or  backward  at  the  front  of  the  shoulder  caused 
pain. 

This  shows  that  the  fracture  can  exist  without  other  symptom  than 
pain  on  pressing  the  fragments  together,  and  that  crepitus  on  moderate 
movements  of  the  limb  may  be  absent ;  which,  indeed,  is  not  surprising 
when  it  is  remembered  how  easily  the  head  can  move  in  its  socket  and, 
consequently,  how  likely  it  is  to  share  in  the  movement  of  the  lower 
fragment  if  it  is  at  all  closely  connected  with  it  by  irregularities  of  the 
line  of  fracture.  Probably  the  most  that  can 
be  said  in  any  case  is  that  there  is  a  fracture 
above  the  surgical  neck,  but  whether  it  is  purely 
of  the  anatomical  neck  or  combined  with  frac- 
ture through  the  tuberosities  or  even  partly  of 
the  neck  and  partly  through  the  tuberosities  is 
likely  to  remain  uncertain,  because  the  deter- 
mining fact — the  relations  of  the  upper  part  of 
the  greater  tuberosity  with  the  shaft,  its  move- 
ment with  it  or  its  independence  of  it — may 
easily  be  beyond  exact  determination. 

Of  fracture  through  the  tuberosities  the  ex- 
amples are  much  more  numerous.  To  a  frac- 
ture of  the  anatomical  neck  may  be  added  one 
or  more  lines  of  fracture  passing  from  the  first 

through    the  tuberosities,  or  the  line  may  pass 

Fracture  of  the  anatomical  along  the  lower  (posterior  and  internal)  portion 
neck  of  the  humerus,  with  of  the  ueck  and  then  diverge  through  the  tuber- 
siight  splintering  and  frac-  Qgj^jgg^     ^pj^^    ^^^^^j^    Specimens    have  almost  all 

been  obtained  from  cases  of  combined  fracture 
and  dislocation,  and  our  periodical  literature 
now  contains  almost  every  year  one  or  more  instances.  I  have  had 
two  such,  fracture  of  the  anatomical  neck  with  Assuring  of  the  greater 
tuberosity,  in  which  I  removed  the  head,  and  have  seen  two  others 
under  the  care  of  colleagues. 

The  distinction  between  this  variety  and  the  higher  form  of  fractures 


Fig.  120. 


ture   of    both 

(GURLT.) 


tuberosities. 


FRACTURES  OF   THE  HUMERUS. 


245 


of  the  surgical  neck  (as  I  have  here  defined  the  latter)  is  arbitrarily 
drawn  and  I  doubt,  for  the  reasons  given,  if  it  can  often  be  recognized 
clinically.  Because  of  its  mode  of  production — violence  acting  directly 
against  the  upper  end  of  the  bone  from  the  outer  side  or  in  front — it 


Fig.  121. 


Fig.  122. 


Impaction  of  the  head  of  the  humerus  into 
the  shaft,  with  splitting  off  of  the  tuberosi- 
ties.    (R.  W.  Smith.) 


Fracture    through     the     tuberosities     of    the 
humerus.      Reversal    of     the    head.       (R.    W. 

Smith.) 


is,  I  think,  much  more  frequently 
associated  with  dislocation  of  the 
upper  fragment  than  are  fractures 
at  a  somewhat  lower  level  which 
seem  more  commonly  to  be  caused 
by  cross-strain .  Independent 
mobility  of  only  the  upper  part  of 
the  tuberosity  would  at  least  show 
that  the  fracture  was  high. 
Two  specimens  described  and  pictured  by  R.  ^Y.  Smith^  (Figs.  121 

and  122)  show  healing  with  marked  impaction  in  one  case  and  with 

complete  reversal  of  the  head  in  the  other.    For  description  of  details 

see  previous  editions. 

A  similar  case  is  reported  by  Kronlein^  and  one  by  Korte.^     (See 

also  Gurlt,  vol.  ii,  p.  693.) 

Repair  is  largely  carried  on  by  the  distal  portion  of  the  bone,  and  is 

marked  by  an  exuberant  production  of  callus  and  osteophytic  growths 

on  the  surface  and  sometimes  by  ossification  of  the  adjoining  portion 

of  the  capsule. 

Of  the  fate  of  the  small  upper  fragment  after  fracture  of  the  anatom- 


1  R.  W.  Smith;  Fractures  in  the  Vicinity  of  Joints,  1854,  p.  192. 

2  Kronlein:  Deutsche  Zeitschrift  f.   Chirurgie,   1S74,   p.   1. 
'  Korte:  Langenbeck's  Archives,   1JS82,  vol.  xxvii,   p.  749. 


246  FRACTURES. 

ical  neck  we  have  little  positive  knowledge.  Boyer's  statement  th&t 
in  bis  case  the  fragment  had  been  diminished  by  absorption  has  been 
extensively  quoted,  but  as  the  patient  died  only  seven  days  after  the 
injury  was  received  the  accuracy  of  the  observation  is  doubtful. 
Kocher  does  not  state  the  result  in  his  cases,  but  in  McBurney's  in 
which  the  fragment  was  restored  to  its  place  by  operation,  and  in  mine 
in  which  a  presumably  similar  fragment  was  restored  to  its  place  by 
manipulation,  and  in  my  other  in  which  the  fragment  was  not  dislo- 
cated and  the  diagnosis  is  not  certain,  recovery  with  good  function  fol- 
lowed. Probably  the  head  in  most  cases  retains  some  vital  connection 
through  untorn  portions  of  the  capsule,  and  experience  at  other  joints 
shows  that  similar  fragments  can  reunite  or  can  remain  as  unirritating 
loose  bodies  in  the  joint. 

Treatment.  Treatment  is  clearly  limited  to  immobilization  of  the 
joint,  possibly  aided  by  some  traction  to  oppose  the  tendency  of  the 
muscles  to  draw  the  shaft  upward  and  thus  displace  the  head. 

C.  Fractures  of  the  Tuberosities. 

Partial  fracture  of  the  greater  tuberosity,  that  is,  the  fracture  of  a 
larger  or  smaller  portion  comprising  some  or  all  of  the  facets  to  which 
the  supraspinatus,  infraspinatus,  and  teres  minor  muscles  are  attached, 
is  a  not  infrequent  accompaniment  of  anterior  dislocation  of  the 
humerus,^  and  has  also  been  seen  by  Malgaigne^  in  a  case  of  disloca- 
tion backward  under  the  acromion.  (See  Anterior  Dislocations  of  the 
Shoulder. )     Fracture  of  the  lesser  tuberosity  is  much  more  rare. 

A  number  of  cases  have  been  reported  of  fracture  of  the  greater 
tuberosity  with  symptoms  so  closely  resembling  those  of  dislocation 
that  the  diagnosis  of  the  latter  lesion  was  at  first  made  in  each  case, 
and  a  study  of  the  reports  make  it  seem  probable  that  this  diagnosis 
was  correct,  the  dislocation  having  then  been  unwittingly  reduced 
during  the  manipulations ;  most  of  the  specimens  found  at  autopsies 
probably  belong  in  the  same  class. 

Before  the  use  of  the  a:-rays  had  become  general,  a  few  cases  were 
seen  in  which  the  injury,  not  associated  with  dislocation,  was  demon- 
strable ;  that  is,  after  a  violent  muscular  eifort  pain  was  felt  at  the 
shoulder,  and  examination  showed  diminution  of  active  outward  rota- 
tion, and  pain  at  the  tuberosity  when  the  eifort  was  made  and  on 
pressure  at  the  same  point,  other  injuries  being  excluded.  In  one  of 
my  cases  the  character  of  the  injury  and  the  course  were  entirely  clear. 
The  fragment  could  be  felt  with  crepitus,  and  the  muscular  act — out- 
ward rotation  and  abduction  of  the  arm — had  been  unaccompanied  by 
a  pull  or  other  violence.  In  two  of  my  cases  there  was  a  tardy  ecchy- 
mosis  on  the  front  of  the  arm,  just  below  the  tendon  of  the  pectoralis. 

Of  late  a  large  ninnber  of  cases  in  which  the  diagnosis  was  made  or 
verified  by  the  .r-rays  have   been   reported.     Graessner^  and  Jacob'* 

1  For  a  review  of  a  number  of  cases,  see  Wohlgemuth,  Deutsche  Gesellschaft  fiir  Chir., 
1900,  ii,  p.  375. 

-  Malgaigne:  Atlas,  Plate  xxii.  Figs.  5  and  6. 

3  Graessner:  Veroff.  aus  dem  Gebiete  Militar-Sanitats,  Hft.  35,  p.  ISO. 

4  Jacob:  Gaz.  des  Hop.,  1903,  pp.  109,  123, 


FRACTURES  OF   THE  HUMERUS. 


247 


have  found  it  frequently  after  falls  upon  the  shoulder,  and  think  it  a 
frequent  cause  of  the  stiffness  which  follows  such  l)lows.  Graessner 
saw  23  examples  in  three  years ;  20  were  due  to  direct  violence,  3  to  a 
fall  upon  the  outstretched  hand.  Melchior  ^  saw  30  cases  in  eight 
years. 

AVhen  the  fracture  accompanies  dislocation  its  Hue  nsuallv  runsaloug; 
the  sulcus  making  the  anatomical  neck  at  the  part  where  it  adjoins  the 
tuberosity  and  down  the  bicipital  groove,  sometimes  liberating  the  long 
tendon  of  the  biceps  from  its  sheath  and  allowing  it  to  slip  in  between 
the  fractured  surfaces.  If  the  separation  is  complete  the  fragment  is 
drawn  upward  and  backward;  if  incomplete,  that  is,  if  the  periosteum 
remains  untorn  on  the  side  of  the  fragment  adjoining  the  shaft,  new 
bone  fills  up  the  lower  part  of  the  gap,  and  the  upper  part  of  the  frag- 
ment stands  out  from  the  surface  from  which  it  has  been  torn,  as  in 
Fig.  123.       When  union  takes  place  it  is  almost  always  bony. 

I  believe  that  in  most,  if  not  all,  cases  in  which  the  fracture  is  not  an 
incident  of  a  dislocation  the  cause  is  the  direct  action  of  the  attached 
muscles.  Some  writers  ascribe  it  almost  Avithout  exception  to  direct 
external  violence,  but  in  the  absence  of  proof  that  this  opinion  is  not 
based  simply  upon  the  patient's  supposition,  its  correctness  may  be 
questioned.  While  writing  this  paragraph  I  was  called  to  a  patient 
with  this  injury,  who  declared  positively  that  it  was  caused  by  a  fall 
upon  the  shoulder;  but  he  admitted,  on  questioning,  that  his  only  reason 
for  thinking  the  shoulder  had  received  a 
l)Iow  was  that  immediately  after  the  fall  he 
felt  pain  in  it.  There  was  no  bruise  of  the 
skin  and  the  fragment  was  a  mere  scale  from 
the  surface  of  the  tuberosity.  The  diagnosis 
must  be  made  by  localized  pain  on  pressure 
and  on  attempted  voluntary  outward  rota- 
tion of  the  arm  against  resistance,  and  pos- 
sibly by  the  abnormal  mobility  of  the  frag- 
ment with  crepitus  or  by  the  a;-rays. 

Treatment.  The  treatment  is  immobili- 
zation with  as  much  outward  rotation  of  the 
arm  as  is  practicable  in  order  to  diminish 
the  pull  of  the  attached  muscles.  Any  tend- 
ency to  inward  displacement,  such  as  was 
noted  by  Smith,  should  be  opposed  by  a  pad 
in  or  below  the  axilla.  Keen  in  1907  (per- 
sonal communication)  exposed  the  fragment 
and  sutured  it  as  nearly  in  place  as  he 
could  bring  it;  and  Niehaus^  says  he  has 
done  it  several  times.  Wohlgemuth  says 
Schuler  in  two  cases  relieved  the  limitation  of  al)duction  caused  by 
contact  of  the  fragment  with  the  acromion  by  chiselling  away  a  portion 
of  the  tuberositv. 


Fm.  123. 


Fracture  of  the  greater  tuberosity 
of  the  humerus  united. 


Molfhoir:   Boitra«c  zur  klin.  Chir.,  1910,  vol.  Ixxv,  pt.  1. 
Xiehaus:  Arch.  klin.   Chir.,    1904,   vol.  ixxiii,  p.  71. 


17 


248  FRACTURES. 

Fractures  of  the  lesser  tuberosity  are  much  less  frequent.  Gurlt  col- 
lected only  three  cases,  two  of  them  accompanying  dislocation  of  the 
shoulder,  the  third  a  specimen  in  the  museum  at  Giessen.  In  each  of 
the  first  two  a  small  hard  lump  could  be  felt  on  the  inner  side  of  the 
head  of  the  humerus,  not  moving  with  it.  A  few  other  cases,  associated 
with  anterior  dislocation,  have  been  reported,  among  them  2  by  Bar- 
denheuer,^  10  collected  by  Delbet,^  and  6  by  RiedeP  in  combination 
with  fracture  of  the  greater  tuberosity  in  the  course  of  15  reductions 
by  arthrotomy.  The  only  case  not  so  associated  and  which  seems 
beyond  question  is  that  of  Lorenz,*  whose  paper  may  be  profitably  con- 
sulted for  an  analysis  of  reported  cases.  His  patient  was  a  man  forty- 
five  years  old,  whose  arm  was  forced  into  outward  rotation,  with  an 
audible  crack.  He  was  treated  for  a  contusion.  When  seen,  three 
months  later  by  Lorenz,  active  inward  rotation  was  almost  lost,  out- 
ward rotation  increased  40°,  and  a  bony  irregularity  tender  on  pressure 
oould  be  felt  at  the  site  of  the  lesser  tuberosity.  A  slightly  movable 
piece  of  bone  could  be  indistinctly  felt  below  the  coracoid.  The  out 
lines  of  the  shoulder  were  normal. 

Jossel  ^  reports  two  cases  accompanying  backward  dislocation  of  the 
shoulder  (q.  v.)  ;  in  both  the  tuberosity  remained  attached  to  the  sub- 
scapularis,  and  in  one  it  was  broken  into  two  pieces.  Engel^  reports 
one. 

Treatment.  The  treatment  would  be  immobilization  in  inward  rota- 
tion, possibly  aided  by  pressure  on  the  outer  aspect  of  the  shoulder  to 
oppose  a  tendency  to  outward  displacement. 

D.  Separation  of  the  Epiphysis. 

The  upper  epiphysis  of  the  humerus  comprises  the  head  and  the 
tuberosities.  The  epiphyseal  line  runs  upward  and  outward  along  the 
lower  and  inner  half  of  the  anatomical  neck  and  then  transversely 
under  or  through  the  tuberosities  to  the  outer  edge,  its  level  rising  as 
the  individual  grows  older,  and  passing  above  part  of  the  insertion  of 
the  teres  minor.  Its  centre  is  higher  than  its  edge,  so  that  the  shaft 
terminates  in  a  low  cone  or  wedge,  with  a  corresponding  hollow  on 
the  under  surface  of  the  epiphysis.  This  cone  is  very  low  in  early 
life  and  its  height  increases  as  the  individual  grows  older,  until  ossi- 
fication of  the  conjugal  cartilage  takes  place,  usually  by  the  twentieth 
year,  but  sometimes  as  late  as  the  twenty-fifth. 

This  lesion  has  been  observed  at  all  ages  between  the  moment  of 
birth  and  the  age  of  nineteen  years.  Jetter,^  in  an  account  of  sixteen 
cases  operated  upon  by  Bruns,  mentions  two  cases  aged  twenty-three 
and  twenty-four  years,  but  no  mention  is  made  of  the  presence  of  the 

1  Bardenheuer:  Deutsche  Chirurgie,   Lief  63  a.  p.   168. 

2  Delbet:  Arch.  gen.  de  Med.,    1893,   p.   14. 
3Riedel:  Die  Heilkunde,  1899,  4,  quoted  by  Dolhnger. 

4  Lorenz:  Deutsche  Zeitschrift  fiir  Chir.,  1900-01,  vol.  Iviii,  p.  593. 
6  Jossel:  Deutsche  Zeitschrift  fiir  Chir.,   1784,  vol.  iv,  p.  125. 
6  Engel:  Arch,  fiir  klin.  Chir.,  1897,  vol.  Iv,  p.  603. 
'  Jetter:  Beitriige  zur  klin.  Chir.,  1892,  vol.  ix,  p.  361. 


FRACTURES  OF   THE  HUMERUS. 


249 


conjugal  cartilage  in  either,  and  in  one  the  line  of  fracture  followed 
that  of  the  epiphyseal  junction  for  only  half  an  inch.    Both,  I  think, 


Fig.  124. 


Fig.  125. 


Separation  of  the  upper  epiphysis  of  the  humerus  ;  dis- 
placement forward  of  the  lower  fragment.   (Moore.) 

Fig. 126. 


Upper  epiphysis  of  the  humerus  at 
10  years ;  separated  by  maceration. 
Outer  side.    (Moore.) 

Fig.  127. 


Wepaiatiou  of  upper  epiphysis  of  humerus 

belong  in  the  class  of  fractures  after  ossification   of  the  cartilage 
are  examples  of  the  rather  common  high  fractures  of  the  surgical 


and 
neck 


250 


FRACTURES. 


in  which  the  hne  of  fracture  frequently  follows  the  former  epiphyseal 
lines  quite  closely.  In  bi^  cases  collected  by  J.  Hutchinson,  Jr./  6 
occurred  at  birth,  4  during  the  first  year,  and  1 7  at  or  above  the  age  of 
fifteen  years.  In  a  considerable  number  of  the  recorded  cases  it  was 
produced  by  the  efforts  of  the  midwife  or  physician  to  hasten  delivery 
by  drawino^  upon  the  presenting  arm,  or  with  the  finger  hooked  into 
the  axilla,  or  to  bring  down  the  arm  from  the  side  of  the  head  when 
the  legs  and  body  were  already  delivered.  In  others  it  has  been  caused 
by  falls,  by  forcibly  drawing  the  arm  upward  and  outward,  and  by  a 
fall  upon  the  elbow  when  it  was  held  behind  the  axillary  line.  See 
also  a  paper  l)y  Linser.^ 

Fig.  128. 


Separation  of  the  epiphysis,  with  an  oblique  fragment  from  shaft.    Outward  displacement  of 

shaft,    (v.  Beuxs.) 

Considering  how  easily  the  epiphyses  can  be  separated  by  the 
cross-strain  produced  in  forcibly  carrying  the  limb  beyond  the  normal 
limit  of  motion  in  the  corresponding  joint  established  by  the  capsule, 
ligaments,  and  muscles  attached  to  it,  it  seems  probable  that  this  is 
the  mechanism  in  most  cases,  and  in  this  may  probably  be  included 
forced  rotation  of  the  arm. 

The  opportunities  for  direct  examination  of  the  seat  of  injury  have 
been  largely  increased  of  late  by  operations  undertaken  for  the  correc- 
tion of  the  displacement,  often  while  recent.  They  show  that  the  line 
of  fracture  almost  always  follows  the  epiphyseal  line  clo.sely  and  that 
the  periosteum  remains  untorn  to  a  considerable  extent,  especiallv  po.s- 
teriorly,  and  that  where  torn  its  separation  often  takes  place  at  some 
distance  below  the  line  of  fracture,  the  portion  between  the  rent  and 
the  line  of  fracture  being  stripped  from  the  shaft  and  remaining 
attached  to  the  epiphysis  as  an  irregular  sleeve.  The  younger  the 
patient  the  more  marked  apparently  is  this   sleeve  formation. 

The  displacement  is  habitually  of  the  shaft  forward,  and  sometimes 


1  J.  Hutchinson,  Jr.:  British  Medical  Journal,  July  8,  1893. 

2  Linger:  Beitrage  zur  klin.  Chir.,  1900-01,  vol.  xxix,  p.  350. 


FRACTURES  OF   THE  HUMERUS. 


251 


to  the  outer  or  to  the  inner  side,  the  posterior  portion  of  the  end 
of  the  shaft  usually  lodging  in  the  saucer-shaped  lower  surface  of  the 
epiphysis,  the  latter  being  flexed  and  abducted  (Fig.  124).  Excep- 
tionally the  displacement  inward  of  the  up])er  end  of  the  shaft  may 
be  such  as  completely  to  separate  the  fractured  surlaces  and  lodge  the 
end  of  the  shaft  beneath  the  coracoid  process.  There  is  reason  to 
think  that  in  some  cases  there  is  no  displacement.  The  upper  frag- 
ment may  be  rotated  outward. 

Symptoms.  The  symptoms  are  so  characteristic  that  it  is  difficult  to 
understand  why  the  mistake  of  supposing  the  injury  to  be  a  disloca- 
tion should  have  been  made  so  frequently.  The  anterior  edge  of  the 
upper  end  of  the  shaft  can  be  distinctly  felt  at  the  front  of  the  shoulder 
an  inch  or  more  below  the  acromion,  and  often  so  raises  the  skin  that 
its  presence  can  be  seen  as  well  as  felt.  The  arm  usually  hangs 
straight  with  the  elbow  directed  a  little  backward,  or  it  may  be 
abducted,  but  the  suggestion  of  a  dislocation  which  the  latter  attitude 
gives  is  at  once  removed  by  palpation  of  the  shoulder  which  shows  the 
head  of  the  humerus  to  be  in  its  place,  and  if  the  head  is  grasped 
between  the  thumb  and  fingers  and  the  arm  gently  rotated  the  inde- 
pendent mobility  of  the  two  will  be  recognized,  perhaps  with  crepitus. 
The  ajiterior  displacement  of  the  upper  end  of  the  shaft  is  well  shown 
in  Fig.  126. 


Fig.  129. 


Fig.  130. 


Separation  of  upper  epiphysis  of  humerus.    Excision 
of  projecting  end  of  shaft.    (Kocher.) 

In  cases  without  displacement  the  di- 
agnosis could  be  made  only  by  the  local- 
ized pain  on  pres.sure,  on  pressing  the 
elbow  upward,  and  on  attcm])ting  to 
use  the  limb. 

If  displacement  is  absent  or  has  been 
corrected  repair  takes  place  habitually 
without  incident,  although  occasionally 
Union  after  separation  of  the  upper  ^j^^,  trauma  has  Icd  to  premature  ossifica- 

epiphysis  of  the  humerus  with  displace-      .  „     ,  •  i  -i  i 

meut.   (R.W.Smith.)  tiou  01  t lie  conjugal  cartilage  and  conse- 

quent arrest  of  growth,  a  matter  of  spe- 
cial importance  here  because  the  greater  part  of  the  growth  of  tiie 
humerus  in  length  takes  place  at  its  u})per  end. 


252  FRACTURES. 

When  the  displacement  persists  various  results  are  possible:  union 
may  take  place  (Fig.  129),  and  the  subsequent  range  of  motion  be 
restricted  by  the  deformity  ;  as  the  epiphysis  is  already  flexed  and 
abducted  motion  of  the  arm  in  those  directions  is  restricted,  and 
motion  in  other  directions  may  be  interfered  with  either  by  the  faulty 
position  in  some  respects  {e.  g.,  inward  rotation)  of  the  lower  fragment 
or  by  the  contact  of  projecting  portions  with  adjoining  apophyses.  Or 
suppuration  may  follow ;  in  the  reported  cases  it  is  not  entirely  clear 
that  the  suppuration  was  not  provoked  by  injudicious  attempts  to 
reduce  a  supposed  dislocation,  or  that  it  may  not  have  been  a  sponta- 
neous osteomyelitis  preceding  the  separation  of  the  epiphysis,  the  latter 
being  the  result,  not  the  cause,  of  the  suppuration.  Or,  very  rarely, 
reunion  may  fail. 

In  respect  of  treatment  the  first  effort  must  be  to  correct  the  dis- 
placement ;  this  can  sometimes  be  effected  by  traction  upon  the  arm 
aided  by  direct  pressure  upon  the  projecting  fragment,  but  in  other 
cases  it  is  advisable  to  use  the  plan  suggested  by  Dr.  E.  M.  Moore,  that 
of  forcibly  raising  the  elbow  beside  the  head  so  as  to  bring  the  shaft 
into  a  position  corresponding  with  that  taken  by  the  epiphysis ;  as  the 
latter  is  prevented  by  the  posterior  portion  of  the  capsule  from  moving 
further  in  this  direction,  the  forced  movement  of  the  arm  throws  the 
upper  end  of  the  shaft  backward  into  place.  Interposition  of  the  torn 
and  loosened  periosteal  sleeve  may  create  so  serious  an  obstacle  that 
reduction  cannot  be  effected  without  the  aid  of  an  incision  exposing  the 
seat  of  fracture.  In  the  older  cases  ossification  of  the  untorn  periosteum 
rapidly  produces  a  bony  bridge  between  the  fragments  which  pre- 
vents reduction.  In  two  such  cases  Kocher  cut  away  the  projecting 
portion  of  the  shaft  (Fig.  130)  and  increased  the  range  thereby ;  others 
have  resected  the  callus  and  a  portion  of  the  diaphysis  and  then  made 
reduction. 

After  reduction  immobilization  of  the  limb  for  three  or  four  weeks 
is  necessary.  It  is  only  in  cases  in  which  reduction  is  incomplete  that 
measures  are  required  to  oppose  a  tendency  to  recurrence  of  the  dis- 
placement. 

E.  Fracture   of  the   Surgical  Neck. 

Under  this  rubric  are  here  included  fractures  of  the  portion  of  the 
bone  lying  between  the  site  of  the  epiphyseal  cartilage  and  the  insertion 
of  the  pectoralis  and  teres  major,  the  great  majority  of  all  fractures  of 
the  upper  end  of  the  bone.  The  line  of  fracture  in  separation  of  the 
epiphysis  in  the  young  marks  the  upper  limit  of  this  group  in  adults ; 
its  lower  limit  is  an  arbitrary  and  ill-defined  one  and,  moreover,  is  not 
infrequently  crossed  by  fractures  which  lie  partly  above  and  partly 
below  it.  The  higher  fractures  of  the  group  are  separately  described 
by  some  as  fracture  through  the  tuberosities,  fractura  pertubercalaris, 
but  the  distinction  does  not  seem  worth  preserving. 

The  common  cause  is  external  violence,  a  fall  or  a  blow  upon  the 
arm,  but  occasionally  is  muscular  action.  The  mode  of  action  is  rarely 
clear  in  the  history  of  a  given  case,  but  experiment  has  thrown  light 


o 
o 


FRACTURES  OF   THE  HUMERUS. 


253 


upon  it.  The  higher  fractures  may  be  caused  by  a  })low  or  fall  upon 
the  uppei-  part  of  the  arm  or  upon  the  elbow,  presumably  aided  by  the 
resistance  of  the  glenoid  fossa  or  the  acromion,  the  so-called  "com- 
pression "  fractures,  but  much  more  frequently,  I  think,  by  a  cross- 
strain  in  which  the  upper  end  is  fixed  by  the  resistance  of  the  ca])sule 
and  ligaments  and  possibly  the  muscles,  and  either  the  elbow  is  forced 
outward  or  forward  or  is  hxed  in  abduction  while  the  blow  is  received 
on  the  outer  part  of  the  shoulder,  "abduction  fractures;"  "adduction 
fractures,"  by  violence  acting  in  the  opposite  direction,  are  much  rarer. 
The  lower  fractures  may  be  caused  by  violence  acting  on  the  side  of 
the  shaft  at  or  below  the  point  of  fracture,  or  by  cross-strain  in  a  fall 
on  the  elbow  or  hand,  or  by  torsion  of  the  limb. 

In  the  higher  and  some  of  the  lower  fractures  the  line  is  essentially 
transverse,  usually  with  splintering  or  even  comminution,  sometimes 
with  fissures  extending  through  the  head  and  sometimes  with  notable 
impaction.    Many  of  the  lower  fractures  are  oblique,  often  markedlv  so. 


Fig.  131. 


Fig.  132. 


Upper  and  lower  limits  of  fracture 
of  the  surgical  neck  of  the  humerus 
with  spiral  fracture  of  shaft  extend- 
ing into  the  area. 


Impacted  fracture  of  the  .surgical  neck  of  the  humerus. 
(R.  W.  Smith.) 


The  upper  fragment,  since  opposition  to  the  action  of  the  muscles 
attached  to  it  is  duninished  or  annulled  by  the  fracture,  often  takes  the 
attitude  of  flexion,  abduction,  and  outward  rotation,  being  sometimes 
aided  therein  by  the  impaction  into  it  of  the  lower  fragment  (Plate  VI.) ; 
the  latter  is  usually  displaced  inward,  partly  by  the  momentary  con- 
tinuation of  the  fracturing  force  in  some  cases  and  ])artly  by  the  action 
of  the  pectoralis  and  teres  major.      Exceptionally  tlie  tlisphicement  is 


254 


FRACTURES. 


equal  to  the  thickness  of  the  shaft,  and  may  be  outward  or  posterior,  as 
shown  in  some  of  the  figures;  but  in  the  great  majority  of  cases  the 
displacement  is  too  slight  to  be  clinically  recognizable. 

An  important  form  of  impaction  is  that  in  which  the  shaft 
passes  to  the  front  and  outer  side  of  the  head  and  the  latter 
is  thereby  brought  to  a  lower  point  on  its  inner  side  (Fig.   132). 


Fig.  133. 


Fig.  134. 


Fig.  135. 


Fig.  136. 


Figs.  133-136.    Forms  of  fracture  at  the  upper  end  of  the  humerus.    a;-ray  tracings. 

It  is  claimed  by  Hutchinson  that  the  rising  of  the  shaft  under  the 
pull  of  the  deltoid  may  press  the  head  so  far  inward  and  downward 
that  the  final  position  may  resemble  that  of  a  dislocation  below- the 
coracoid. 

The  tendon  of  the  long  head  of  the  biceps  may  be  torn  in  these 
extreme  di.splacements.  Injury  of  the  axillary  vessels  and  nerves  is 
extremely  rare;  thrombosis  of  the  artery  in  consequence  of  bruising  has 
been  seen,  the  axillary  vein  has  been  torn  in  a  compound  fracture,  and 


FRACTURES  OF   THE  HUMERUS. 


255 


the  musculo-spiral  nerve  has  been  so  compressed  as  to  cause  paralysis 
of  motion  and  sensation  in  its  area  of  distribution. 

In  an  obhque  fracture  the  sharp  end  of  the  lower  fragment  may 
approach  or  become  engaged  in  or  even  perforate  the  skin,  usually  on 


Fig.  137. 


Fig.  138. 


Fig.  139. 


Fig.  140. 


Figs.  137-140.     Forms  of  fracture  at  the  upper  end  of  the  humerus.     j;-ray  tracings. 

the  inner  side,  and  even  in  the  higher  fractures  this  has  been  observed 
in  front  close  below  the  acromion. 

For  the  combination  of  fracture  with  dislocation  see  Dislocation  of 
the  Shoulder,  Chapter  XLIV. 

Symptoms.  The  symptoms  vary  with  the  form  of  fracture  and  the 
displacement;  usually  the  arm  hangs  by  the  side  or  the  elbow  is  slightly 
abducted,  but  if  the  displacement  inward  of  the  upper  end  of  the  shaft 


256 


FRACTURES. 


is  marked  the  abduction  of  the  arm  resembles  that  of  an  anterior  dis- 
location (Fig.  142) ;  the  distinction  is  easily  made  by  recognition  of  the 
presence  of  the  head  in  the  glenoid  fossa,  maintaining  the  fulness  of  the 
shoulder.  Loss  of  function  is  usually  complete,  swelling  marked,  and 
ecchymoses  very  extensive,  especially  in  the  old,  often  spreading  to  the 
elbow  and  across  the  front  of  the  chest. 

If  the  elbow  is  pressed  upward  pain  is  felt  at  the  fracture,  and  dis- 


Fig.  141. 


Fig.  142. 


Fracture  of  the  surgical  neck  of  the 
humerus.  The  dark  spot  is  an  ecchy- 
mosis. 


Fracture  of  tlie  surgical  neck  ;  displacement 
inward  of  the  lower  fragment,  resembling  dis- 
location. 


tinctly  localized  pain  can  often  be  caused  by  pressure  with  the  finger 
along:  the  line  of  fracture. 

Then  if  the  upper  fragment  is  grasped  between  tlie  thumb  and  fingers 
in  such  a  way  that  the  notch  between  the  tuberosities  at  the  bicipital 
groove  can  be  felt,  and  the  elbow  is  gently  rotated,  the  failure  of  the 
former  to  share  in  the  movement  will  be  recognized  and  usually  crepi- 
tus will  be  perceived.  In  the  cases  with  more  marked  displacement  the 
relations  of  the  fragments  can  be  determined  by  palpation  if  the  patient 
is  not  too  fat  or  the  region  too  swollen,  or  by  noting  the  direction  of  the 
axis  of  the  shaft. 

Diagnosis.  In  the  great  majority  of  cases  the  diagnosis  is  made  upon 
the  localized  pain,  especially  on  pressing  the  elbow  upward,  and  on  the 
failure  of  the  tuberosities  to  share  in  slight  rotatory  movements  com- 
municated to  the  elbow,  for  the  displacement  is  usually  too  slight  to  be 


FRACTURES  OF   THE  HUMERUS.  257 

recognized  through  the  swollen  tissues.  When  marked  displacement 
exists  the  position  of  the  upper  end  of  the  lower  fragment  is  indicated 
by  the  direction  of  the  axis  of  the  shaft,  generally  upward  and  inward, 
and  is  demonstrated  by  abnormal  resistance  to  pressure  and  pain  at  the 
indicated  point,  usually  corresponding  to  the  groove  between  the  pec- 
toraiis  and  deltoid  near  the  coracoid.  Dislocation  of  the  shoulder  is 
excluded  by  recognition  of  the  head  in  its  place.  The  lower  end  of 
the  upper  fragment  can  be  traced  only  in  those  oblique  fractures  where 
the  line  of  fracture  descends  upon  the  shaft. 

Prognosis.  When  no  important  displacement  persists  and  no  coni]Ui- 
cations  are  present,  the  course  is  uneventful  and  the  result  good  ;  union 
takes  place  in  from  thirty  to  forty  days,  and  the  restoration  of  function 
is  complete  after  a  few  more  weeks.  Exce])tionally,  function  may  be 
diminished  by  an  associated  arthritis,  especially  in  the  old,  or  by  exces- 
sive formation  of  callus  in  the  higher  forms.  Failure  of  union  has 
been  noted  in  only  a  very  few  cases  with  uncorrected  displacement; 
and  once  or  twice  the  displaced  end  of  the  shaft  has  become  firmly 
adherent  to  the  coracoid  process. 

Treatment,  lieduction  of  the  displacement  is  made  by  traction  upon 
the  arm  aided  by  appropriate  pressure  on  the  end  of  the  lower  frag- 
ment. In  most  cases,  because  of  the  usual  abduction  of  the  upper 
fragment,  it  is  necessary  to  make  traction  with  the  arm  widely  abducted 
so  as  to  bring  the  shaft  into  line  with  the  attitude  of  the  upper  frag- 
ment, and  after  the  displacement  has  thus  been  reduced  the  arm  is 
lowered  to  the  side  and  there  maintained  by  suitable  dressings  unless 
this  position  too  greatly  favors  recurrence  of  the  displacement,  in  which 
case  the  abducted  position  must  be  maintained  for  a  week  or  two. 
Exceptionally,  another  attitude  may  be  made  necessary  by  another 
form  of  dis])lacement. 

The  chief  disturbing  influence  which  the  retentive  dressing  has  to 
oppose  is  the  action  of  the  muscles,  which  tends  to  draw  the  lower  frag- 
ment upward  and  inward  and  to  flex,  abduct,  and  sometimes  outwardly 
rotate  the  upper  fragment,  and  the  great  difficulties  in  the  preparation 
of  an  always  effective  dressing  are  to  find  a  fixed  support  for  its  upper 
end  which  will  furnish  the  counter-extension  for  traction  upon  the 
lower  segment  and  to  oppose  the  tendency  to  displacement  inward  with- 
out making  undue  pressure  upon  the  vessels  and  nerves  of  the  axilla 
and  inner  aspect  of  the  arm.  The  upper  fragment  is  too  small  to  be 
acted  upon  directly  by  any  splint,  and  its  position  and  movements  can 
be  controlled  only  through  its  interlocking  with  the  lower  fragment ; 
in  default  of  such  control  the  lower  fragment  must  be  brought  into  line 
with  the  upper  in  the  position  given  to  the  latter  by  its  attached  mus- 
cles. Counter-extension  against  the  folds  of  the  axilla  is  ineffective 
both  because  they  are  yielding  and  because  they  rest  upon  nnisclcs,  the 
pectoralis  and  latissimus  dorsi,  which  are  attached  to  the  humerus 
below  the  seat  of  fracture,  so  that  the  force  is  applied  to  the  twt)  ends 
of  the  lower  segment  and  is,  therefore,  ineffectual  to  control  its  rela- 
tions to  the  upper  one.  The  desired  fixation  can  be  got  by  a  heavy 
plaster-of-Paris  dressing  enveloping  the  chest  and  shoulder,  but  this  Is 
too  irksome  to  be  used  except  in  cases  of  extreme  need.     I  have  used 


258  FRACTURES. 

it  with  advantage  in  some  compound  fractures.  Fortunately  the  ten- 
dency to  displacement  can  usually  be  controlled  by  simple  measures 
which  are  sufficiently  effective  in  practice  even  if  not  in  theory,  but 
when  it  is  great  continuous  traction  must  be  used,  either  by  weight  and 
pulley  with  the  patient  in  bed,  or  by  a  weight  attached  to  the  dependent 
arm  when  the  patient  is  seated  or  standing. 

Lateral  displacement  inward  of  the  upper  end  of  the  shaft  can  be 
effectively  opposed  when  the  patient  is  in  bed  by  moderate  traction 
outward  applied  by  a  band  about  the  upper  part  of  the  arm.  ISo  fixed 
dressing  or  splint  can  alone  do  it,  when  the  tendency  is  marked,  because 
of  the  presence  of  the  main  vessels  and  nerves  on  the  inner  side  of  the 
arm  where  they  might  be  dangerously  compressed  between  the  bone 
and  the  upper  part  of  the  splint.  Fixed  dressings  consist  essentially 
of  a  stiff  piece  on  the  outer  side  of  the  limb,  resting  against  the  shoul- 
der and  elbow,  to  which  the  arm  is  made  fast  by  a  bandage ;  this  meas- 
urably controls  inward  displacement  but  not  shortening.  If  the  latter 
threatens  it  must  be  opposed  by  traction,  although  that  supplied  by  the 
weight  of  the  limb  is  usually  sufficient.  Occasionally  the  fixed  dress- 
ing is  a  simple  support  between  the  arm  and  the  body,  by  which  the 
limb  is  immobilized  in  abduction  ;  and  not  infrequently  it  is  sufficient 
simply  to  bind  the  arm  to  the  side  of  the  body. 

Continuous  traction  by  weight  and  pulley  is  made  through  a  cord 
attached  to  the  arm  above  the  elbow  by  two  strips  of  adhesive  plaster 
bound  to  it  by  a  roller  bandage  as  in  the  similar  treatment  of  frac- 
tures of  the  thigh  (page  105).  The  hand  and  forearm  should  be 
bandaged  to  prevent  swelling.  The  patient  should  be  in  bed,  the 
arm  somewhat  abducted,  the  forearm  preferably  vertical ;  weight 
about  five  pounds.  It  is  rarely  necessary  to  maintain  it  for  more 
than  two  weeks. 

Traction  with  the  patient  out  of  bed  can  be  made  by  a  weight  simi- 
larly attached  to  the  arm  or  hanging  from  a  plaster-of-Paris  dressing 
as  described  below  ;  the  elbow  is  flexed  at  a  right  angle,  and  the  fore- 
arm supported  at  the  to-ist  by  a  sling. 

The  common  shoulder-cap  of  leather  or  cardboard,  capping  the  shoul- 
der and  covering  the  outer  aspect  of  the  arm,  or  even  extending  to  the 
elbow,  is  wholly  inefficient  against  inward  displacement  or  overriding 
and  serves  only  to  give  support  and  to  protect  against  chance  violence. 
It  must  be  combined  with  an  internal  lateral  splint  to  give  it  more 
control  over  the  lower  fragment  and  with  traction  to  prevent  over- 
riding. 

A  similar  dressing  of  plaster  of  Paris  enveloping  the  arm  and  fore- 
arm and  overlapping  the  shoulder  has  the  same  defects,  although  they 
are  diminished  by  the  better  control  of  the  limb  and  by  the  weight 
of  the  dressings  which  makes  efficient  traction  when  the  patient  is 
erect.  It  can  safely  be  used  when  the  tendency  to  displacement  is 
slight,  especially  after  the  second  week.  It  can  be  readily  made  as 
shown  in  Fig.  147  or  with  the  usual  plaster  roller-bandage,  applied 
lightly  over  the  forearm  and  more  thickly  on  the  arm  as  high  as  the 
axilla,  and  combined  with  a  cap  over  the  shoulder  made  by  carrying 
the   bandage  up  and   down  over   it   from   the  outer  side  of  the  arm. 


FRACTURES  OF   THE  HUMERUS. 


259 


Overriding  taking  place  undc^r  it  can  be  detected  by  noticing  that 
the  cap  rises  abo\'e  the  shoulder,  admitting  the  finger,  or  even  two, 
beneath  it;  this  must  be  met  by  attaching,  a  weight  to  the  elbow, 
and  in  all  cases  the  forearm  should  be  supported  across  the  chest, 
only  at  the  wrist,  in  order  that  the  weight  of  the  arm  may  constantly 
draw  the  lower  fragment  do-^m  when  the  patient  is  erect.  A  triangular 
cushion  extending  from  the  axilla  to  the  elbow  between  the  arm  and 
the  chest  secures  slight  abduction  if  needed  and  may  add  to  the  com- 
fort (Fig.  149). 


Fig.  143. 


Fig.  144. 


r\ 


Hennequin's  plaster  splint  for  fracture  of  the  humerus. 


A  convenient  method  of  making  a  similar  plaster  dressing  is  that 
devised  by  Hennequin  : '  a  dozen  thicknesses  of  crinoline,  or  three  or 
four  of  muslin  or  canton-flannel,  cut  as  shown  in  Fig.  143,  the  width 
being  equal  to  the  circLunference  of  the  arm,  and  the  length  of  the 
central  portion  equal  to  the  distance  from  the  fold  of  the  axilla  to  the 
elbow,  are  soaked  in  plaster  cream  and  applied  as  shown  in  Fig.  144, 
the  limb  having  previously  been  bandaged  from  the  Avrist  to  the  elbow 
to  prevent  swelling.  If  overriding  is  present  or  anticipated  traction 
must  be  made  while  the  plaster  is  hardening,  either  by  the  hands  or  by 
a  weight  made  fast  at  the  elbow  by  a  bandage  under  the  splint.  Hen- 
nequin makes  temporary  counter-extension  by  a  bandage  under  the 
axilla,  but  I  doubt  its  value  or  safety  ;  it  seems  liable  to  lead  to  making 
tiie  splint  too  high  on  the  inner  side  and  thus  chafing  the  axillary 
folds. 


Heuncquiu  :  Revue  de  Chirurgie,  1887. 


260  FRACTURES. 

For  cases  in  which  the  attitude  and  fixation  of  the  upper  fragment 
are  such  that  the  hmb  must  be  kept  abducted  so  as  to  be  in  Hue  with 
it,  and  in  which  confinement  to  bed  must  be  avoided,  a  support  braced 
against  the  body  may  be  used,  sucli  as  a  bent  strip  of  tin  or  stout 
leather,  or  a  cushion  (Fig.  149),  or  the  arm  and  chest  may  be  enveloped 
in  plaster  of  Paris. 

The  choice  of  these  different  methods  in  varying  cases  may  be 
summarized  as  follows:  In  the  high  fractures  with  little  displacement 
or  tendency  thereto  moderate  immobilization,  support,  and  protection 
are  sufficient,  and  these  may  often  be  got  by  binding  the  arm  to  the 
side,  especially  if  the  patient  is  fat.  If  the  patient  is  robust,  and 
especially  if  the  fracture  is  oblique,  so  that  shortening  by  the  traction 
of  the  muscles  is  probable,  a  plaster-of-Paris  dressing  with  traction 
by  a  weight  at  the  elbow  is  required.  If  the  upper  fragment  is  abducted 
and  its  position  cannot  be  controlled  by  interlocking  of  the  broken 
surfaces,  the  abducted  position  of  the  arm  is  necessary,  and  the  patient 
should  be  treated  in  bed  with  traction  in  that  position  for  a  fortnight, 
when  the  upper  fragment  will  generally  be  found  to  accompany  the 
lower  one  when  it  is  adducted,  or  out  of  bed  with  a  supporting  dressing. 
Cases  with  marked  tendency  to  displacement  inward  of  the  upper 
end  of  the  lower  fragment  should  be  treated  in  bed  with  traction  in 
abduction  aided  by  moderate  outward  traction  upon  the  upper  part 
of  the  lower  fragment. 

Compound  fractures  which  suppurate  need  a  strong  fixed  support 
which  can  be  maintained  during  the  changes  of  dressing,  such  as  a 
plaster-of-Paris  jacket  with  iron  braces  extending  across  to  a  plaster 
case  enveloping  the  lower  two-thirds  of  the  arm  or  with  a  strong  broad 
plaster  bridge  uniting  the  two  over  the  top  and  outer  aspect  of  the 
shoulder.  In  compound  fractures  with  splintering  of  the  upper  frag- 
ment and  implication  of  the  joint,  usually  gunshot,  excision  of  the  head 
favors  repair  and  the  subsequent  usefulness  of  the  limb. 

In  all  cases  the  patient  should  be  directed  to  move  his  wrist  and  fin- 
gers freely;  and  fixed  dressings  should  be  removed  as  early  as  possible, 
and  the  limb  supported  only  in  a  sling  and  protected  by  a  removable 
shoulder-cap  extending  to  the  elbow,  in  order  that  massage  may  be  used 
to  hasten  the  restoration  of  function. 

For  the  treatment  of  fracture  combined  with  dislocation  see  Dislo- 
cation of  the  Shoulder. 

2.  FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS. 

The  region  is  that  included  between  the  insertion  of  the  pectoralis 
major  and  the  upper  portion  of  the  supracondyloid  ridges. 

All  the  varieties  of  fracture  which  may  occur  in  long  bones  are  con- 
tained among  those  of  the  shaft  of  the  humerus.  A  remarkable  and 
unique  example  of  longitudinal  fracture  extending  the  entire  length  of 
the  bone  is  quoted  in  Chapter  II  (p.  27),  and  Gurlt  gives  two  of  excep- 
tionally long  fissures,  beginning  in  the  one  case  at  the  condyles  and 


FRACTURES  OF  THE  HUMERUS. 


261 


Fig. 


ending  at  the  insertion  of  the  deltoid,  and  extending  in  the  other  from 
the  upper  border  of  the  greater  tuberosity  to  the  lower  fourth  of  the 
shaft.     Incomplete  or  partial  fractures  are  extremely  rare. 

All  the  forms  of  displacement  common  to  fractures  of  the  long  bones 
are  also  found  here,  and  no  one  deserves  mention  as  of  exceptional 
frequency  and  importance.  The  character  of  the  pri- 
mary displacement  depends  largely  upon  the  fracturing 
force ;  that  of  later  displacement  upon  the  unsupported 
weight  of  the  limb  and  upon  muscular  action. 

Double  fractures  of  the  same  bone  are  very  rare. 
Simultaneous  fracture  of  both  humeri  has  been  caused 
by  epileptic  convulsions  and  by  external  violence. 

Among  the  injuries  which  may  be  associated  with 
the  fracture  are  dislocation  of  the  shoulder,  laceration 
of  the  soft  parts,  and  contusion  or  rupture  of  blood- 
vessels or  nerves.  The  latter  deserve  special  attention 
because  of  the  gangrene  of  the  limb  or  the  paralysis 
which  may  result  and  may  be  attributed  to  negligence 
in  the  treatment.  The  brachial  artery  or  vein  may 
be  so  crushed  or  bruised  by  direct  violence  that  a 
thrombus  forms  within  it  and  arrests  the  circulation; 
or,  more  rarely,  it  may  be  torn  by  the  sharp  edge  of 
a  displaced  fragment,  or  the  vessel  may  be  stretched 
across  the  fragment  in  such  a  way  as  to  be  occluded 
by  pressure.  Occasionally  the  injury  to  the  artery  has 
resulted  in  the  formation  of  an  aneurism.  The  mus- 
culo-spiral  nerve  is  particularly  exposed  to  injury 
because  of  its  close  relations  to  the  bone  throughout 
so  large  a  part  of  its  course.     (See  p.  78.) 

Causes.  The  causes  of  fracture  are  external  violence  and  muscular 
action;  the  latter  causes  fracture  in  the  humerus  more  frequently  than 
in  any  other  bone,  and  the  causative  effort  has  not  always  been  \'ery 
great.  The  two  most  common  efforts  which  have  caused  it  are  tin-ow- 
ing a  stone  and  that  trial  of  strength  in  which  two  men  clasp  hands 
with  elbows  resting  on  a  table  and  strive  each  to  force  the  other's  hand 
aside;  the  latter  produces  a  spiral  fracture. 

Compound  fractures  have  no  anatomical  peculiarities  that  require 
mention.  Gurlt  collected  five  cases  of  almost  complete  severance  of 
the  arm  by  a  blow  with  an  axe  or  sabre,  all  of  which  recovered  with 
preservation  of  the  limb;  in  all  the  wound  was  on  the  outer  and  anterior 
aspect  of  the  limb. 

Symptoms.  The  symptoms  are  the  usual  ones:  abnormnl  mobility, 
crepitus,  loss  of  function,  pain,  and  more  or  less  deformity.  Imi)or- 
tant  complications,  such  as  dislocation  of  the  shoulder  or  injury  of  the 
artery  or  a  nerve,  have  their  special  sym])t()ms;  the  principal  danger  is 
that  they  may  be  overlooked  because  the  attention  is  concentrated  on 
the  fracture.  Injury  to  the  artery  is  indicated  by  absence  or  weakness 
of  the  radial  pulse,  either  immediately  or  after  the  lapse  of  a  few 
18 


;,<!" 


Longitudinal  frac- 
ture of  the  humerus. 

(GUELT.) 


262 


FRACTURES. 


hours;  sometimes  the  symptoms  have  appeared  gradually,  the  pulse 
becoming  weak,  and  finally  disappearing,  the  hand  numb  and  cold,  the 
surface  bluish,  and  after  death  or  amputation  a  clot,  sometimes  firm, 


Fig.  146. 


Fig.  147. 


Plaster-of-Paris  splints  for  fracture  of  the  shaft  of  the  humerus. 

pale,  and  adherent,  sometimes  dark  and  soft,  has 
been  found  in  the  artery.  Injury  of  a  nerve, 
usually  the  musculo-spiral,  is  shown  by  paralysis 
and  loss  of  sensation  or  hypersesthesia  in  the  region 
supplied  by  it;  paralysis  or  loss  of  sensation  indi- 
cates division  or  destruction  of  the  nerve ;  hyperses- 
thesia indicates  irritation,  usually  by  pressure. 
Paralysis  of  motion  is  often  overlooked  at  first. 

A  simple  fracture  in  an  adult,  running  its  course 
without  complications,  will  be  solidly  united  in  from 
four  to  six  weeks,  and  in  three  or  four  weeks  in  chil- 
dren. The  possible  complications  are  inflammation 
and  delayed  union;  the  former  is  sometimes  quite  marked,  and  the 
latter  is  of  more  frequent  occurrence  in  the  humerus  than  in  any 
other  bone.  The  general  and  local  causes  which  lead  to  delay  in  or 
failure  of  union  have  been  discussed  in  Chapter  VIII.     It  has  been 


Fracture  of  lower  por- 
tion of  shaft;  angular 
displacement;  cubitus 
varus. 


FRACTURES  OF  THE  HUMERUS.  263 

thought  that  the  special  cause  in  the  case  of  the  humerus  is  defective 
immobiHzation  of  the  fragments,  for  when  the  elbow  is  kept  at  a 
right  angle  any  vertical  movement  of  the  hand  or  forearm  is  likel\'  to 
cause  horizontal  movement  of  the  lower  fragment  on  the  upper  one, 
and  lateral  splints  cannot  be  fitted  accurately  or  snugly  enough  to 
pre\'ent  it.  This  is  best  avoided  by  using  plaster  splints  which  include 
the  shoulder.  The  supposed  interposition  of  muscle  which  has  been  so 
frequently  alleged  as  the  cause  has  existed  in  none  of  the  cases  upon 
which  I  ha\'e  operated  because  of  failure  of  union. 

Treatment.  Reduction  is  made  by  traction  upon  the  condyles  or  the 
flexed  forearm.  The  treatment  in  fractures  of  the  upper  third  is  essen- 
tially the  same  as  in  fractures  of  the  surgical  neck;  rest  in  bed,  with 
continuous  traction  and  the  limb  supported  upon  cushions,  may  be 
required  at  first.  For  the  lower  fractures  abduction  of  the  limb  is  not 
so  often  needed.  The  plaster-of-Paris  bandage  in  common  use  is 
more  secure  than  lateral  splints,  and  gives  good  results,  but  it  needs 
careful  watching  at  first,  both  to  detect  displacement  and  to  prevent 
strangulation  of  the  limb.  It  should  be  carried  from  the  \M-ist  to  the 
shoulder,  and  may  include  a  few  spica  turns  over  the  shoulder  and 
about  the  chest  to  aid  immobilization  and  oppose  overriding.  The  fore- 
arm shoidd  be  flexed  and  supported  by  a  sling  at  the  wrist.  Snug 
support  under  the  elbow  in  low  fractures  can  produce  an  angular 
deviation  inward  of  the  lower  fragment  (Fig.  146),  which  greatly  dis- 
figures the  limb,  especially  when  the  forearm  is  extended ;  this  deformity 
is  considered  in  detafl  in  the  subsequent  section  on  Supra-condyloid 
Fractures.  A  posterior  moulded  plaster  or  wire  splint,  extending 
under  the  forearm  and  over  the  back  of  the  shoulder  (Fig.  147),  is  con- 
venient and  efficient.  A  weight  attached  to  the  elbow  is  sometimes 
useful  to  prevent  shortening  or  to  overcome  that  which  is  already 
present;  it  will  lengthen  a  limb  even  after  the  lapse  of  two  or  three 
weeks. 

I  have  found  it  advantageous  in  cases  of  fracture  by  direct  violence, 
especially  in  women  and  the  alcoholic,  to  keep  the  patient  in  bed  for 
about  a  week,  or  until  the  danger  of  acute  inflammatory  complications 
had  passed.  Stromeyer's  cushion,  designed  particularly  for  the  treat- 
ment of  compound  fractures,  is  useful  as  a  support.  It  lias  the  form 
of  a  triangular  pyramid  (Fig.  14S),  the  long  lines  of  which  are  tweh'e 
to  fifteen  inches  long.  It  should  be  firm  enough  to  keep  its  sha])e  under 
pressure,  and  its  upper  end  should  be  blunter  than  shown  in  the  figure. 
It  is  secured  in  place  by  tying  the  upper  ])air  of  stra])s  al)out  the 
opposite  shoulder  and  the  lower  pair  about  the  waist.  A  similar  but 
smaller  cushion  (Fig.  149)  is  sometimes  used  in  connection  with  an 
ambulatory  dressing  like  the  preceding. 

In  the  treatment  of  compound  fractures  the  general  ])rinci])l('s  hud 
down  in  Chapter  VII  are  to  be  followed.  Sus])ension,  as  shown  in 
Figs.  150,  151,  and  152,  facilitates  change  of  dressings  and  adds  to  the 
patient's  comfort  during  confinement  to  the  bed.  If  he  is  out  of  l)ed 
moulded  plaster  splints  can  be  placed  outside  the  dressings. 


264 


FRACTURES. 


Fig.  148. 


Fig.  149. 


Stromeyer's  cushion  applied.  Small  Stromeyer  cushion  for  ambulatory  treatment. 


Fig.  150. 


Suspension  and  extension:  fracture  of  humerus.     (Flint.) 


FRACTURES  OF  THE  HUMERUS. 


2Qi 


When  there  is  reason  to  fear  serious  injury  to  bloodvessels  or  nerves 
fixed  dressings  and  bandages  should  be  avoided  until  after  the  extent 
of  the  injury  shall  have  become  apparent.  Reduction  should  be  made 
as  completely  as  possible  and  the  limb  supported  upon  cushions  or 
suspended. 


1m.;.  151. 


Suspension  and  tiai-Hun:    Iracuire  ol  humerus.     (Flint.) 

Fig.  152. 


Fracture  of  leg  and  humerus.     (Flint.) 

If  there  is  reason  to  believe  that  the  musculo-spiral  nerve  has  been 
ruptured,  it  should  be  sought  in  the  groove  between  the  supinator  and 
])rachialis  anticus  and  traced  to  the  ]:)oint  of  injury,  and  siitin-ed.  Or 
the  operation  may  be  delayed  two  or  three  weeks  in  order  that  re])air 
may  be  well  advanced  and  the  dangers  of  infection  thereby  lessened. 
If  the  paralysis  appears  only  after  the  lapse  of  a  few  weeks  it  is  prob- 
ably due  to  inclusion  of  this  nerve  in  callus  or  cicatrical  tissue,  which 
must  then  be  relieved  by  open  operation.     (See  Chapter  W,  p.  78.) 


266  FRACTURES. 


3.  FRACTURES  OF  THE  LOWER  END  OF  THE  HUMERUS. 

This  group,  like  that  of  fractures  at  the  upper  end  of  the  humerus, 
includes  a  number  of  varieties  diifering  materially  in  character  and 
importance,  and  having  in  common  only  their  position  near  the  elbow, 
and  the  frequent  necessity  and  difficulty  of  making  a  differential  diag- 
nosis between  each  and  the  others  and  dislocation.  The  terms  applied 
to  the  different  forms  are  :  Supracondyloid,^  intercondyloid  or  T-shaped, 
fracture  of  the  external,  or  internal,  condyle,  of  the  internal  epicondyle 
or  epitrochlea,  of  the  external  epicondyle,  of  the  articular  process 
(capitellum  and  trochlea),  and  separation  of  the  epiphysis.  In  the 
supracondyloid  are  here  included,  although  an  etymological  objection 
can  fairly  be  made,  some  of  those  few  low  fractures  to  which  Kocher 
has  given  the  name  diacondylica .^ 

The  relative  frequency  of  the  different  forms  cannot  at  present  be 
determined  with  entire  accuracy  from  hospital  and  dispensary  records, 
in  the  preparation  of  which  different  surgeons  take  part.  Personal 
predilection  for  one  or  another  form  seems  to  have  a  misleading  in- 
fluence in  the  obscure  cases.  At  the  Out-patient  Department  of  the 
House  of  Relief  during  a  term  of  six  years  ending  in  1904,  97  of  these 
fractures,  excluding  those  of  the  epitrochlea,  were  received,  divided  as 
follows  :  External  condyle  45,  supracondyloid  26,  intercondyloid  9,  in- 
ternal v'^ondyle  15,  separation  of  epiphysis  1,  edge  of  trochlea  1.  Ex- 
amination of  the  individual  records  convinced  me  that  some  of  those 
classed  as  of  the  internal  condyle  were  supracondyloid.  Sixty-two  of  the 
patients  Avere  under  eleven  years  of  age,  18  others  were  less  than  twenty 
years  old,  15  were  more  than  twenty  years  old.  More  confidence  is  to 
be  placed  in  the  statistics  of  surgeons  who  have  made  a  special  study 
of  the  injury,  and  have,  presumably,  made  the  diagnosis  in  each  case, 
and  usually  with  the  aid  of  the  a;-rays.  Thus,  Ashhurst^  gives  56  cases  : 
"  supracondylar,  including  diacondylar,  29,  external  condyle  12,  epi- 
trochlea 3,  epiphyseal  7,  internal  condyle  4  (2  doubtful),  intercondylar 
1."  And  Treves^  gives  :  supracondyloid  86,  external  condyle  42,  epi- 
trochlea 34  5  (abstract  in  Ztlblatt  fiir  Chir.,  1912,  p.  241).  It  is  beyond 
question  that  supracondyloid  and  fractures  of  the  external  condyle  com- 
prise the  great  majority  of  all  cases,  and  that  fracture  of  the  internal 
condyle  is  very  infrequent. 

The  great  relative  frequency  of  these  fractures  in  children  makes 

necessary  a  brief  account  of  the  somewhat  complex  development  of  this 

.end  of  the  bone.     According  to  Henle,  the  epiphysis  at  birth  is  wholly 

cartilaginous  below  a  transverse  line  passing  through  the  lower  part 

of  the  olecranon  fossa  ;'  in  a  month  or  two  this  line  descends  centrally 

1  The  substitute  term  supracondylar  is  gaining  favor. 

2  Kocher's  small  group,  fractura  diacondylica,  composed  of  two  widely  different  lesions 
produced  in  two  very  different  ways,  compression  and  avulsion,  it  does  not  seem  desirable 
to  preserve.  The  avulsion  variety  I  have  placed  among  fractures  of  the  articular  process. 
Ashhurst  practically  makes  a  new  grouping  under  this  term  by  applying  it  to  the  much 
more  numerous  low  supracondyloid  fractures,  a  differentiation  which  seems  to  be  clinic 
ally  undesirable. 

3  Ashhurst :  Fractures  of  the  Elbow,  p.  38. 

^  Treves :  Fractures  de  I'extremite  inferieure  de  I'humerus  chez  I'enfant. 

6  This  number  is  so  large  that  it  probably  includes  cases  complicating  dislocation. 


FRACTURES  OF  THE  HUMERUS. 


267 


to  the  lower  edge  of  the  fossa,  becoming  convex,  and  during  the  first 
or  second  year  a  centre  of  ossification  appears  in  the  capitelhnn. 
Between  the  eighth  and  twelfth  years  this  nodule  enlarges,  nearly  or 


Fig.  153. 


Twelfth  to  fifteenth  year.  Eighth  to  twelfth  year.  First  to  second  year. 

Ossification  of  the  lower  epiphysis  of  the  humerus. 

quite  reaching  the  trochlear  groove,  a  nodule  appears  in  each  epicon- 
dyle,  and  the  diaphysis  sends  a  prolongation  down  into  the  inner  por- 
tion   of  the  trochlea.     Between   the   twelfth  and    fifteenth   years  the 

Fig.  154. 


Skiagram  oi  normal  elbow  at  atje  of  five  year.s 


nodule  of  the  cupitellum  unites  with  that  ot  its  epicondyle,  and  after 
that  the  final  point  of  ossification,  that  of  the  trochlea,  ap])ears ;  it  is  a 
thin  concave  cap  or  shell,  closely  ap])lied  to  the  downward  ])r())cction 
of  the   corresponding  portion  of  the  diaphysis,  and  unites   with    the 


268 


FRACTURES. 


nodule  of  the  capitellum  about  the  fifteenth  year;  soon  afterward  the 
nodule  formed  by  the  union  of  the  troclilea,  capitellum,  and  external 
epicondyle  unites  with  the  diaphysis,  and  subsequently  the  nodule  of 
the  internal  epicondyle  unites.    Kocher's  statement,  following  Farabeuf, 


Normal  epiphysis  of  humerus  at  age  of  eight  years. 


that  the  trochlear  nodule  is  the  first  to  unite  with  the  diaphysis  seems 
to  be  an  error  due  to  misinterpretation  of  the  peculiar  descent  of  the 
diaphvsis  into  the  trochlea,  probably  through  ignorance  of  the  late 


Fig.  156. 


Fig.  157. 


Supracondyloid  fracture  of  the 
humerus. 


Skiagram  showing  lower  epiphysis  at  eleven 
years  (Ashhurst). 


appearance  ot  the  trochlear  nodule.  It  thus  appears  that  the  epiphysis 
after  about  the  fifth  year  is  an  irregular  strip  of  cartilage  containing 
one  or  two  bony  nodules  in  its  thicker  outer  portion,  and  none  in  its 
thin  saucer-like  trochlear  portion,  which  latter  is  continuous  by  a  sort 


FRACTURES  OF   THE  HUMERUS. 


269 


of  neck  with  the  cartilaginous  and  bony  internal  epicondyle.  ]My  own 
specimens  and  skiagrams  indicate  that  the  end  of  the  diaphysis  after 
the  sixth  year  is  much  more  directly  transverse,  descends  lower  on  the 
outer  side  than  is  shown  in  Fig.  153.  Possibly  the  difference  in  ap- 
pearance depends  upon  the  direction  of  the  line  of  section,  Henle  carry- 
ing it  further  forward  on  the  outer  side  so  as  to  include  more  of  the 
projecting  capitellum. 


A.    Fractures  Above  the  Condyles — Supracondyloid. 

Tlie  line  of  fracture  may  be  transverse  or  oblique,  and  oblique 
either  from  side  to  side  or  from  before  backward,  and  it  may  open 
the  joint  by  crossing  the  olecranon  or  coronoid  fossa  or  by  the  exten- 
sion into  it  of  a  fissure  between  the  condyles.     It  may  lie  above  both 

epicondyles,  or  above  one  and  below 
Fig.  158.  the  other,  and,  at  least  at  an   early 

age,  may  coincide  in  whole  or  in  part 
with  the  epiphyseal  line.  This  defini- 
tion brings  into  the  group  those  of 
Kocher's  fractura  diacondylica,  in 
which  the  lower  fragment  includes  a 
part  of  either  condyle,  and  in  separa- 
tion of  the  epiphysis  in  young  chil- 
dren the  line,  in  most  if  not  all  cases, 
lies  within  the  same  region. 

The  cause  is  violence  acting  upon 
the  front  or  back  of  the  lower  end 
of  the  bone,  usually  through  the  bones 
of  the  forearm,  as  in  a  fall  u])on  the 
outstretched  hand,  or,  as  indicated 
by  Kocher's  experiments,  by  torsion. 
Possibly,  also,  it  may  be  caused  by 
a  blow,  as  in  a  fall  upon  the  point 
of  the  flexed  elbow,  the  direction  of 
the  force  being  forward  and  upward. 
The  commonest  cause  appears  to  be  a 
fall  upon  the  hand  in  which  the  end 
of  the  humerus  is  pressed  backward 
("extension  fracture  ")  either  directly  by  the  partly  flexed  forearm  or 
possibly  by  hyperextension  of  the  joint.  In  this  case  the  line  of  fracture 
is  oblique  from  behind  downward  and  forward,  the  lower  end  of  the 
upper  fragment  often  ending  in  a  sharp  point  on  its  anterior  aspect  (Fig. 
100).  When  the  force  acts  in  the  opposite  direction,  against  the  back 
of  the  elbow,  a  much  more  rare  occurrence,  and  the  lower  end  of  the 
humerus  is  forced  forward  ("flexion  fracture"),  the  line  of  fracture 
runs  from  in  front  downward  and  backward,  and  the  sharp  point  is 
found  at  the  upper  end  of  the  lower  fragment  in  front  (Fig.  101).  l^'igs. 
106  and  1()7  represent  a  specimen  of  this  kind  which  I  obtained  from 
a  patient  who  died  of  delirium  tremens  shortly  after  the  accident. 


Upper  and  lower  limits  of  supracondyloid 
fracture. 


270 


FRACTURES. 


While  carrying  a  flagstone  he  fell  upon  the  elbow,  flexed  at  a  right 
angle,  v:ith  the  edge  of  the  stone  resting  in  the  flexure  of  the  joint; 
the  fracture  was  almost  exactly  in  the  frontal  plane,  as  if  the  condyles 
had  been  cut  oft'  by  an  axe  descending  along  the  anterior  surface  of 


Fig.  159. 


Kocher's  experimental /raciwra  diacondylica  hy  direct  violence. 

the  humerus.     In  both  forms  the  hio;her  the  fracture,  the  less,  appa- 
rently, is  the  obliquity.     An  adduction  fracture  in  the  young  may  be 


Fig.  180. 


Fig.  161. 


'  Extension  "  and  "  flexion  "  fractures  of  lower  end  of  the  humerus. 


classed  as  a  low  form  of  this  ;  the  fracture  starts  close  above  the  ex- 
ternal epicondyle  and  runs  along  or  close  above  the  epiphyseal  line 
toward  or  to  the  epitrochlea,  or  diverges  downward  through  the  trochlea 
into  the  joint  (Fig.  168);  the  displacement  is  angular,  pivoting  on  the 


FRACTURES  OF   THE  HUMERUS. 


271 


inner  side,  and  if  it  remains  uncorrected  or  recurs,  marked  cubitus 
varus  results. 


Fig.  162. 


Fig.  163. 


Ext 


Supracondyloid  fracture  (,or  separation  of  epiphysis)  at  eight  years ;  three  weeks  old :  x,  Peri- 
osteal growth ;  x-ray  tracing. 


Fig.  164. 


Fig.  165. 


Supracondyloid  fracture  at  two  and 
a  half  years;  dotted  line  probable  outline 
of  cartilaginous  epiphysis;  a;-ray  tracing. 


Supracondyloid     fracture     at    t'levcn 
years;  a^ray  tracing. 


The  character  and  extent  of  displacement  vary  with  the  dirertion  of 
the  line  of  fracture ;  as  the  latter  is  so  often  oblique  dowmvard  and 


272 


FRACTURES. 


forward,  the  lower  fragment  is  commonly  displaced  backward  and 
upward,  and  not  infrequently  the  sharp  end  of  the  upper  fragment  is 


Fig.  167. 


Fig.  166 


Fig.  16S. 


Supracondyloid  fracture.     Fig.  166.  rear  -s-iew.     Fig.  167.  front  \"iew. 

forced  tln-ough  the  overlying  muscles  and  even  the  skin  on  the  antero- 
internal  aspect.  In  one  case  I  found  on  operation  the  musculospiral 
nerve  ruptured  at  the  edge  of  the  upper  frag- 
ment, and  in  another  the  median  partly  torn 
by  it.  To  this  displacement  backward  may 
be  added,  or  for  it  may  be  substituted,  an 
angular  displacement,  the  apex  directed 
forward,  which  accentuates  the  promi- 
nence of  the  back  of  the  elbow.  In  the 
less  common  cases  in  which  the  obliquity 
is  downward  and  backward  the  displace- 
ment of  the  fragment  is  forward  and  up- 
ward, but  is  much  less  marked  than  in  the 
other  form,  although  occasionally  the  upper 
fragment  has  been  forced  through  the  tri- 
ceps and  the  skin.  If  displacement  per- 
sists the  range  of  motion  in  the  elbow  may 
be  restricted  by  direct  bony  contact  or 
by  fibrous  bands  attaching  the  torn  and 
bruised  muscles  to  the  bone. 

In  the  low  fractures  in  children,  where 
the  line  apparently  often  coincides  more 
or  less  with  the  epiphyseal  junction,  the 
lower  fragment  may  be  displaced  inward, 
or  less  frequently  outward,  and  with  the 
inward  displacement  usually  coexists  an 
angular  displacement  bv  which  the  outer  portion  of  the  lower  fragment  is 
lowered,  and  sometimes  a  backward  displacement  of  its  outer  portion.  The 

1  This  specimen  is  a  close  link  between  Kocher's  experimental  form  of  fyacfura  diacon- 
ch/Iica  by  direct  violence  and  the  common  forms  of  supracondyloid  fracture. 


Experimental  adduction  fracture 
in  a  child. 


FRACTURES  OF   THE  HUMERUS. 
Fig.  169. 


273 


Low  supracondyloid  fracture,  three  weeks  old,  reduced  by  operation. 


Fig.  170. 


Fig.  171. 


Supracondyloiil  fr.-ictiire  vvitli  uiiKular  dis- 
placcmuiit ;  marked  cubitus  varus. 


Supracoiidyliiid  fnicture  with  aii^'iilar  disiilaoe- 
ment ;  marked  cubitus  varus.    Frout  view. 


274  FRACTURES. 

result  of  this  displacement,  if  uncorrected,  is  the  angular  lateral  devia- 
tion of  the  lower  fragment  with  the  apex  directly  outward,  which  is 
shown  in  Figs.  170,  171,  172,  173,  174,  and  in  Plate  X.  The  deformity 
of  the  elbow,  cubitus  varus,  which  results  is  very  noticeable  in  extension 
and  has  usually  been  attributed  solely  to  the  ascent  of  the  internal 
condyle  after  its  fracture;  but  the  almost  total  absence  of  such  speci- 
mens, the  possession  of  others  showing  descent  of  the  external  condyle, 
and  the  findings  in  several  operations  undertaken  to  correct  the  de- 
formity have  convinced  me^  that,  when  marked,  it  is  habitually  the 
result  of  a  complete  or  partial  supracondyloid  fracture  followed  by  this 
angular  displacement,  and  that  this  is  practically  the  only  form  of 
fracture  after  which  it  is  at  all  likely  to  occur  to  any  extent.  A  number 
of  specimens  have  been  described,  and  I  possess  three  (Figs.  146,  170, 
171,  172,  173,  and  174;  those  represented  in  Figs.  171,  172,  173,  and  174 
correspond  almost  exactly  with  the  condition  of  the  bones  shown  in 
the  skiagram  (Plate  X,  Fig.  1)  of  a  limb  very  much  like  Fig.  175. 

Two  frontal  sections  of  the  specimens  shown  in  Figs.  171-174  show 
no  trace  of  fracture,  no  change  in  the  cortex  of  the  juxta-epiphysary 
region,  and  the  outline  of  the  inner  supracondyloid  ridge  is  unbroken, 
but  more  sharply  curved.  The  appearance  is  that  of  elongation  on 
the  outer  side,  and  of  shortening  on  the  inner,  and  suggests  a 
fracture  along  or  close  above  the  epiphysary  line,  incomplete  on 
the  inner  side,  with  angular  displacement  upon  the  inner  portion 
of  the  internal  condyle  as  a  centre.  Presumably  the  mass  between 
the  outer  condyle  and  the  shaft  is  new  bone  formed  by  the  untorn 
periosteum.  Experiment  on  the  cadaver  shows  that  the  posterior 
part  of  the  periosteum  may  remain  untorn  even  when  the  displace- 
ment downward  of  the  outer  part  of  the  fragment  is  considerable,  and 
its  preservation  is  even  greater  when  the  fracture  is  along  or  close  to 
the  epiphyseal  line. 

The  deformity  is  shown  in  Figs.  175  and  176.  The  forearm  is 
adducted  in  full  extension  and  abducted  in  full  flexion.  Because  of 
the  effect  of  rotation  of  the  arm  at  the  shoulder  upon  the  position  of 
the  wrist  with  reference  to  the  shoulder  the  latter  feature — abduction 
in  flexion — can  be  recognized  only  on  comparison  with  the  other  arm, 
and  preferably  while  both  arras  are  in  full  outward  rotation  at  the 
shoulder  so  as  to  insure  symmetry  of  their  positions. 

The  artery  or  the  median  or  musculospiral  nerve  may  be  torn  or 
compressed,  but  this  injury  is  much  less  frequent  than  might  be  antici- 
pated from  the  extent  and  direction  of  the  displacement. 

In  2  cases  of  inward  displacement  of  the  low  form  in  the  young 
I  have  seen  late  sloughing  of  the  skin  by  pressure  against  the  outer 
angle  of  the  upper  fragment.  Savariaud^  reports  4  cases  of  apparent 
injury  to  the  median  and  ulnar  nerves ;  1  recovered  spontaneously, 
1  after  operation,  and  in  2  operation  failed  to  relieve. 

1  Stimson  :  Cubitus  varus,  Annals  of  Surg..  Sept.,  1900. 

2  Savariaud  :  Arch,  gen  de  med.,  1903,  No.  2. 


PLATE  VII 


Fig.  1.  —  Fracture  of  the   Lower  End.   of  the   Humerus. 


Fig.  2. — Supraeonclyloicl    Fracture  of  the   Humerus   by  Extension. 


> 

< 


19 


PLATE  IX 


Fig.  1. — Supraeondyloid  Fracture  of  the   Humerus   by  Extension  in   a  Young  Child. 


Fig.  2. — Supraeondyloid   Fracture  at  Eight  "Vears. 


PLATE  X 


Fig.  1. — Old.  Supraeondyloicl    Fracture  of  the   Humerus.     Cubitus  Varus. 


Fig.  2. — Cubitus  Varus;  Three  Years  after  a   Low  Supraeondyloid  Fracture. 
The  lower  part  of  the  Supinator  Ridge  has  been  cut  away. 


FRACTURES  OF  THE  HUMERUS.  275 

Fig.  172.  Fig.  173. 


x 

M 

p 

Fig.  174. 


Cubitus  varus  after  low  partial  supracoiulyloid  fracture  in  ycjuth,  or  si^parafiou  of  epiphysis;   Fig.  li 
front;  T'ig.  173,  rear;  Fig.  174,  sections,  ending  above  on  posterior  surface. 


276  FRACTURES. 

The  fragment  may  also  be  displaced  forward  or  backward  with 
corresponding  angular  deviation  from  the  longitudinal  axis,  as  in  the 
higher  forms. 

Fig.  175. 


Cubitus  varus. 
Fig.  176. 


Cubitus  varus. 


Symptoms.  The  symptoms  are  deformity,  loss  of  function,  abnormal 
mobility,  and  pain.  The  deformity  may  be  marked  or  slight,  the 
former  especially  when  the  line  of  fracture  is  oblique  from  behind 
downward  and  forward  and  the  lower  fragment  is  displaced  and  tilted 


FRACTURES  OF   THE  HUMERUS.  277 

backward  ;  this  causes  a  prominence  of  the  back  of  the  elbow  which 
in  some  stages  resembles  that  of  a  dislocation,  but  is  readily  distin- 
guished from  it  by  noting  that  the  relations  of  the  olecranon  and  epi- 
condyles  are  normal  and  that  the  head  of  the  radius  is  in  place.  In 
the  young,  when  the  line  of  fracture  passes  below  the  internal  epicon- 
dyle  and  the  lower  fragment  is  displaced  inward,  the  appearance  on 
the  inner  side  is  that  of  an  internal  lateral  dislocation,  and  the  true 
nature  of  the  injury  must  be  determined  by  the  relations  of  the  head 
of  the  radius  and  the  ca])itellum.  The  easy  reduction  of  the  backward 
displacement  by  drawing  the  flexed  forearm  forward,  and  its  easy 
reproduction  by  pressing  the  forearm  backward  has  led  even  expe- 
rienced surgeons  into  error,  and  emphasizes  the  necessity  of  accu- 
rately determining  the  relations  of  the  head  of  the  radius  and  the 
capitellum. 

The  determination  of  these  relations  is  the  first  step  to  be  taken  in 
the  examination  of  most  injuries  of  the  elbow  ;  it  is  conveniently  done 
by  placing  the  tips  of  the  thumb  and  middle  finger  on  the  two  epicon- 
dyles  respectively  and  that  of  the  index-finger  upon  the  point  of  the 
olecranon,  and  noting  their  correspondence  or  lack  of  correspondence 
with  the  normal  in  the  positions  of  extension  and  of  flexion  at  a  right 
angle,  ordinarily  using  the  other  elbow  in  comparison.  The  head  of 
the  radius  can  be  felt  from  one-half  to  three-fourths  of  an  inch  distant 
from  the  external  epicondyle  in  the  direction  of  the  wrist. 

Swelling  is  marked  and  uniform  ;  ecchyraosis  is  usually  present  after 
a  few  hours;  voluntary  motion  is  inhibited  by  pain,  passive  motion 
restricted.  Abnormal  lateral  mobility — adduction  and  abduction  of 
the  forearm — exists  and  is  most  surely  recognized  if  the  test  is  made 
while  the  elbow  is  extended.  If  the  condyles  are  firmly  grasped  with 
one  hand  and  the  shaft  with  the  other,  free  mobility  of  one  upon  the 
other,  usually  with  crepitus,  is  found.  Pressure  upward  with  the  hand 
under  the  flexed  elbow  causes  pain.  Pressing  the  condyles  together 
does  not  cause  pain  unless  the  line  of  fracture  also  runs  between  them 
(T-fracture),  nor  can  the  condyles  be  moved  independently  of  each 
other.  Pressure  with  the  tip  of  the  finger  along  the  supracondyloid 
ridges  may  detect  irregularity  and  cause  pain  at  the  point  of  fracture 
if  the  displacement  is  slight ;  if  it  is  marked  the  lower  end  of  the 
upper  fragment  can  be  readily  recognized,  usually  in  front,  at  or  close 
al)ove  tiie  flexure  of  the  elbow.  Kocher,  analyzing  five  personal  cases 
of  what  he  terms  fractura  diacondylica,  which  corresjxnids  to  that 
described  here  as  the  low  form  in  the  young,  speaks  of  pain  on  pressing 
the  extended  or  flexed  forearm  against  the  arm. 

Treatment.  In  view  of  the  proximity  of  the  joint  the  important  indi- 
cation is  to  secure  repair  without  displacement;  and  the  displacements 
which  threaten  are  the  primary  overriding  in  the  higher  fractures  in 
adults  and  the  late  lateral  angular  deviation  in  the  low  ones  in  children 
(Fig.  170).  The  overriding  can  be  corrected  by  traction,  preferably 
with  the  elbow  at  a  right  angle,  and  its  recurrence  effectively  oji]iosed 
by  anterior  and  posterior  moulded  s])lints,  or  a  plaster  encasement, 
aided  sometimes  by  a  weight  attached  to  the  forearm  close  by  the 
elbow,  with  the  wrist  supported  by  a  sling. 


278 


FRACTURES. 


In  the  low  form  in  children,  which  is,  I  believe,  practically  the 
only  form  of  fracture  at  the  elbow  in  which  the  dreaded  deformity, 
cubitus  varus,  is  liable  to  ensue,  the  principal  factor  in  its  production, 
after  reduction  of  the  primary  displacement,  is,  I  think,  the  action  of 
gravity  when  the  forearm  is  supported  across  the  front  of  the  body.  In 
experiments  upon  the  cadaver  and  in  operations  to  correct  the  deform- 
ity I  have  repeatedly  seen  the  displacement  appear  when  the  limb  was 
placed  in  this  position,  and  I  have  seen  one  patient  in  whom  it  seemed 
probable  that  it  took  place  within  a  plaster  encasement,  although  it 
is  not  certain  that  reduction  was  made  and  maintained  during  the 
application  of  the  dressing.  After  operation,  recumbency,  with  the 
elbow  at  a  right  angle  and  the  forearm  vertical,  has  always,  in  my 
experience,  prevented  it,  with  the  aid  of  a  thick  envelo])ing  dressing  of 
gauze  rollers.  Probably  it  would  do  equally  well  in  simple  fracture. 
The  confinement  to  bed  need  not  last  more  than  a  week. 

Fig.  177. 


Angular  displacement  produced  by  tit-xion. 

Full  flexion  of  the  elbow,  which  of  late  has  been  urged  in  a  some- 
what exaggerated  and  uncritical  way  as  the  proper  treatment  for  all 
fractures  at  the  elbow,  undoubtedly  holds  the  fragments,  in  this  form  of 
fracture,  more  firmly  together,  apparently  by  the  tension  of  the  triceps 
thus  produced,  or,  as  em])hasized  by  Lusk,i  by  the  untorn  periosteum 
on  the  back  of  the  bone,  but  it  can  itself  produce  an  angular  displace- 
ment (apex  backward),  as  shown  in  Fig.  177,  and,  of  course,  it  is  value- 
less unless  antecedent  reduction  is  made. 

Ashhurst,2  in  his  interesting  and  valuable  study  of  fractures  of  the 
elbow,  strongly  recommends  treatment  in  extreme  flexion  (Figs.  178 
and  179),  and  reports  excellent  results  thereby.  If  the  surgeon  selects 
this  method  of  retention,  he  should  assure  himself  that  full  reduction 

>  Lusk:  Annals  of  Surgery,    1908,  vol.  xlviii,  p.  4.32. 

2  Ashhurst:  Fractures  of  the  Elbow.     Lea  &  Febiger,  1910. 


FRACTURES  OF   THE  HUMERUS. 


279 


has  been  made,  either  pre\'ioiisly  by  noting  the  restoration  of  the  carry- 
ing angle  in  extension,  or,  after  flexion,  by  noting  the  relations  of  the 
wrist  and  shoulder,  as  shown  in  Fig.  176.  After  the  joint  has  been 
fixed  by  the  bandage  the  limb  can,  of  course,  be  rotated  inward,  as  shown 
in  Fig.  179,  without  changing  the  relations  of  the  fragments  to  each 
other.  Treves  employs  the  method  except  in  supracondyloid  fractures 
and  in  those  with  great  displacement.     If  used,  care  must  be  taken 


Fig.  178. 


Fig.  179. 


Dressing  to  maintain  elbow  in  liyperflexion 
first  stage.    (Ashhurst.) 


Dressing  to  maintain  elbow  in  liyperflexion 
completed.    (Ashhurst.) 


not  to  force  the  flexion  lest  the  pressure  should  become  dangerous.  I 
have  seen  very  disabling  ischemic  contraction  caused  by  it,  and  ]\Iurph\' 
has  seen  several  such.  That  the  method  does  not  insure  a  good  result 
is  strikingly  shown  by  Xeuhof  and  \Yolf's^  report  of  100  cases  thus 
treated,  with  53  per  cent,  perfect  and  47  per  cent,  imperfect  results. 
The  correspondence  shown  in  their  tables  between  the  degree  of 
perfection  in  the  result  and  the  brevity  of  the  treatment  is  not  to  be 
taken  as  an  essentially  causative  relation,  for  doubtless  the  length 
of  treatment  was  affected  by  the  severity  of  the  injury. 

The  frequency  with  which  some  deformity  persists  after  this  fracture 
has  led  some  surgeons  to  maintain  that  in  it,  more  perhaps  than  in  any 


1  Neuhof  and  Wolf:   Surg.,   Gyn.  and  Obst.,   March,   1915. 


280 


FRACTURES. 


other  simple  fracture  of  a  long  bone,  a  primary  operation  for  adjust- 
ment and  fixation  is  justifiable  or  even  requisite,  but  Konig^  has  shown 
by  several  skiagrams  taken  at  intervals  of  two  or  three  years  that  even 
very  marked  deformity  disappears  rapidly  in  the  young  by  absorption 
of  projecting  bone  and  the  filling  up  of  hollows,  and  that  functional 
limitations  are  rarely  caused  by  it. 

In  compound  fractures  I  always  use  vertical  suspension  of  the  limb 
for  about  a  fortnight,  unless  the  wound  heals  sooner.  It  is  of  great 
value  in  controlling  reaction  as  well  as  preventing  gross  displacements ; 
minor  adjustments  can  still  be  made  after  the  wound  has  healed  or  has 
become  unimportant. 

In  several  cases  of  low  fracture  in  the  young,  after  the  lapse  of  from 
four  weeks  to  six  months,  I  have  exposed  the  region  through  an  exter- 
nal lateral  incision,  cut  away  all  new  bone,  freed  the  lower  fragment, 
and  brought  it  back  into  place  with  full  restoration  of  form  and  func- 
tion. Occasionally  a  second  incision  on  the  inner  side  is  needed.  In 
some  old  cases  the  deformity  has  been  relieved  by  excision  of  a  wedge- 
shaped  piece  from  the  outer  side  of  the  humerus  just  above  the 
epicondyle,  thus  bringing  the  lower  fragment  into  line  with  the  shaft. 
The  same  could  be  done  in  case  of  angular  displacement,  apex  forward, 
and  thereby  the  hand  would  be  brought  nearer  the  shoulder  in  full 
flexion  of  the  joint. 


Fig.  180. 


B.  Fractures  of  the  Internal  Epicondyle  (Epitrochlea). 

By  the  epitrochlea  is  meant  the  projecting  spur  of  bone  on  the  side 
of  the  trochlea;  its  lower  limit  is  sharply  defined,  but  above  it  is  con- 
tinuous with  the  condyloid  ridge.  The  first  author 
who  called  attention  to  this  fracture  was  Granger,^  in 
1818.  It  is  more  common  in  children  than  in  adults; 
of  ten  cases,  not  associated  with  dislocation  of  the 
elbow,  treated  in  the  House  of  Relief  in  two  and  a 
half  years,  the  ages  were  one,  five,  ten,  ten,  fourteen, 
seventeen,  twenty-eight,  thirty-four,  and  forty-three 
years.  The  fracture  frequently  accompanies  disloca- 
tion of  the  elbow,  being  produced,  I  think,  by  the 
pull  of  the  flexor  muscles  of  the  forearm  which  are 
attached  to  it  and  which  are  put  upon  the  stretch  by 
the  forcible  abduction  of  the  forearm  which  is  so 
commonly  a  first  step  in  the  production  of  a  backAvard 
or  outward  dislocation.  In  cases  not  thus  compli- 
cated the  cause  appears  commonly  to  be  external 
violence  acting  directly  upon  the  back  of  the  epi- 
trochlea. 

Symptoms.     The  symptoms  vary  somewhat  with  the  size  of  the 
fragment,  for  when  the  latter  is  small  it  is  held  in  place  by  the  untorn 


Fracture  of  the 
internal  epicon- 
dyle of  the  hu- 
merus (epitrochlea) . 

(GURLT.) 


1  Konig:  Arnh.  fiir  Klin.  Chir.,  vol.  Ixxxv,  p.  187. 

2  Granger:  Edinburgh  Medical  and  Surgical  Journal,  vol.  xiv,  p.  196. 


FRACTURES  OF   THE  HUMERUS.  281 

portion  of  the  muscular  attachments  upon  it  and  the  adjoining  bone, 
but  when  it  is  large  enough  to  include  the  greater  part  of  the  attachment 
displacement  takes  place  downward  and  forward  in  the  direction  of  the 
muscles.  If  the  swelling  is  not  too  great  the  fragment  can  be  seized 
between  the  thumb  and  finger  and  moved,  usually  with  crepitus.  Ecchy- 
mosis  is  common,  and  the  functions  of  the  joint  may  be  diminished  by 
pain  or  the  fear  of  it.  Pain  is  felt  on  forcible  contraction  of  the  flexors 
of  the  hand. 

In  a  few  cases  the  ulnar  nerve  has  been  injured  by  the  original 
violence  or  irritated  by  pressure  of  the  displaced  fragment  or  a 
portion  of  callus.  In  three  of  Granger's  cases  there  was  partial 
paralysis  of  motion  and  sensation  in  the  region  supplied  by  the 
ulnar  nerve,  and  repeated  crops  of  vesicles  formed  upon  the  correspond- 
ing part  of  the  hand  during  the  two  or  three  months  following  the 
injury.  All  the  symptoms  disappeared  after  a  time.  Kichet^  observed 
a  case  of  fracture  of  the  epitrochlea  with  dislocation  of  the  elbow  in- 
ward due  to  a  fall  ujwn  the  ice.  After  reduction  of  the  dislocation  the 
ulnar  nerve  was  found  to  be  completely  paralyzed.  A  month  later  the 
little  finger  was  so  insensitive  that  the  patient  amused  himself  and 
amazed  his  play-fellows  by  holding  it  more  than  a  minute  in  the  flame 
of  a  candle.  The  deep  burn  which  was  the  result  took  several  weeks 
to  heal ;  afterward  sensibility  returned  gradually  and  became  complete. 

Denuce^  was  consulted  by  a  man  suffering  with  an  intense  neuralgia 
of  the  ulnar  nerve  following  a  fall  upon  the  elbow  three  months  before. 
He  recognized  deformity  of  the  epitrochlea,  made  an  incision,  and 
found  the  nerve  hypertrophied  and  resting  upon  a  bony  prominence 
formed  by  the  epitrochlea  displaced  and  united  in  its  false  position. 
The  projecting  part  of  the  bone  was  excised,  and  the  neuralgia  ceased. 

Treatment.  The  treatment  is  simple  :  immobilization  of  the  elbow 
in  the  flexed  position  so  as  to  relax  the  muscles  that  arise  from  the  epi- 
trochlea and  thus  diminish  the  force  that  tends  to  draw  it  forward  and 
downward.  It  is  futile  to  attempt  to  keep  the  fragment  in  place  by 
pressure  upon  it  from  the  outside.  Even  if  it  remains  displaced  down- 
ward and  forward  the  deformity  is  slight  and  entails  no  loss  of  function. 
Immobilization  should  be  maintained  until  consolidation  has  taken 
place,  the  length  of  time  necessary  for  which  varies  with  the  age  of  the 
patient  and  the  extent  of  the  unreduced  displacement.  In  children, 
and  without  displacement,  union  is  sufficiently  firm  at  the  end  of  ten 
days  or  a  fortnight  to  allow  splints  to  be  laid  aside  and  the  arm  to  be 
carried  in  a  sling,  and  in  three  weeks  the  arm  may  be  left  unsupported 
and  free. 

In  a  few  cases  the  fragment  has  been  excised  because  of  pain  or  fear 
lest  it  should  interfere  with  function;  it  has  also  been  proposed  to 
secure  it  in  place  by  transfixion  with  a  pin  or  by  incision  and  suture, 
but  the  measure  seems  wholly  unnecesary. 

1  Richet:  Anatomie  Medico-Chiriirgicale,  4th  ed.,  p.  672,  note. 

2  Denuce:  Diet,  de  Med.  et  Chir.  Pratiques,  art.  Coude,  p.  721. 


282 


FRACTURES. 


C.  Fractures  of  the  External  Epicondyle. 

This  is  a  much  rarer  accident  than  the  preceding,  and  as  the  fragment 
that  is  broken  off  is  small,  and  as  the  cause  appears  to  be  always  direct 
violence,  which  is  usually  accompanied  by  bruis- 
ing and  swelling,  the  exact  nature  of  the  injury 
may  easily  pass  unrecognized.  An  anatomical 
demonstration  of  the  fracture  has  never  been 
made,  except  in  connection  with  more  extensive 
fractures  of  the  elbow.  In  the  sense  in  which 
the  term  is  here  used  the  epicondyle  is  the  small 
prominence  above  and  on  the  outer  side  of  the 
capitellum,  composed  in  part  of  bone  formed 
about  a  separate  centre  of  ossification,  and  in 
part  of  the  projecting  portion  of  the  shaft  or 
condyle  itself.  To  it  are  attached  the  external 
lateral  ligament  of  the  joint  and  part  of  the 
extensor  muscles  of  the  forearm. 

Most  surgeons  deny  the  possibility  of  an  ex- 
tra-articular fracture  of  this  part,  and  group  all 
fractures  of  the  region  as  of  the  external  condyle. 
Anatomically  speaking,  it  is  certainly  possible  for  such  a  fracture  to 
occur;  the  epicondyle,  though  small,  is  still  large  enough  to  be  broken  in 
such  a  way  that  the  line  of  fracture  may  lie  entirely  outside  the  joint. 
Gurlt  describes  as  extra-articular  fractures  of  the  external  epicon- 
dyle two  specimens  preserved,  the  one  at  Giessm,  the  other  at  Berlin. 
In  each  the  fracture  has  united  with  con- 
siderable displacement  downward  of  the 
fragment,  which  appears  in  the  description 
and  figure  (Fig.  181)  too  large  to  have  been 
entirely  extra-articular.  Still,  his  personal 
examination  of  the  specimens  was  more 
likely  to  lead  to  a  correct  opinion  of  them 
than  a  verbal  description  or  a  figure  is. 

The  cause  must  be  direct  violence,  or 
possibly  forcible  adduction  of  the  forearm 
acting  through  the  lateral  ligament;  the 
displacement  must  be  slight  and  unim- 
portant; the  treatment,  rest. 


Fracture  of  the  external 
epicondyle  of  the  humerus. 
(Gurlt.) 


Fig.  182. 


D.  Fractures  of  the  Internal  Condyle. 


Upper  and  lower  limits  of  fracture 
of  the  internal  condyle. 


The  line  of  fracture  runs  from  a  point 
on  the  inner  border  of  the  epitrochlea  or 
of  the  ridge  above  it  downward  and  outward,  ending  on  the  outer  half 
of  the  lower  part  of  the  trochlea  or  at,  or  even  a  little  beyond,  its 
junction  w^ith  the  capitellum  (Fig.  182). 

The  common  cause  appears  to  be  violence  acting  from  below  upward 
upon  the  trochlea,  as  in  a  fall  upon  the  flexed  elbow  or  by  forced  adduc- 
tion or  abduction  of  the  forearm,  turning  upon  the  head  of  the  radius 


PLATE  Xr 


Fracture  of  Internal  Condyle  of  the  Humerus, 
in  an  Adult. 


X 

H 


20 


FRACTURES  OF   THE  HUMERUS.  283 

as  a  centre,  and  breaking  off  the  condyle  by  forcing  it  upward  or  back- 
ward or  drawing  it  downward  or  forward. 

The  fragment  may  be  displaced  in  any  of  these  directions,  and  may 
also  be  rotated.  As  the  ulna  remains  attached  to  the  fragment  and  is 
itself  held  in  place  by  its  attachments  to  the  radius,  the  displacement  of 
the  fragment  cannot  be  great  unless  there  is  associated  dislocation  of  the 
radius  from  the  capitellum,  as  occasionally  observed.  A  late  displace- 
ment, similar  in  effect  to  that  observed  after  supracondyloid  fracture, 
may  occur  here  also ;  pressure  upward  against  the  flexed  elbow,  as  by  a 
snug  sling,  is  transmitted  through  the  olecranon  to  the  fragment 
and  raises  it  above  its  proper  place,  thus  changing  the  direction  of 
the  transverse  axis  of  the  joint  and  substituting  adduction  of  the 
forearm — cubitus  varus — for  the  slight  normal  abduction.  Possibly 
the  contraction  of  the  triceps  and  brachialis  anticus  may  aid  in  pro- 
ducing this  result.  I  believe,  however,  this  is  a  much  less  frequent 
cause  of  the  deformity  than  displacement  after  supracondyloid  fracture. 

The  swelling,  as  in  most  of  these  fractures  at  the  elbow,  is  uniform, 
rarely  more  marked  on  the  side  of  the  injury  except  at  first;  loss  of 
function  is  marked,  the  arm  generally  being  held  at  an  angle  of  about 
125  degrees,  and  the  range  even  of  passive  motion  without  anaesthesia  is 
restricted.  The  characteristic  symptoms  are  independent  mobility 
of  the  condyle,  usually  with  crepitus,  pain  on  pressing  the  condyles 
together  and  on  pressure  with  the  tip  of  the  finger  at  the  point  where 
the  line  of  fracture  crosses  the  supracondyloid  ridge,  and  sometimes  an 
irregularity  in  the  line  of  the  ridge  at  that  point.  The  independent 
mobility  is  recognized  by  grasping  the  fragment  between  the  thumb 
and  fingers  and  moving  it  slightly  backward  and  forward  while  the 
other  condyle  and  the  shaft  are  held  with  the  other  hand.  Pain  can 
also  be  caused  by  pressure  upward  against  the  olecranon  or  backward 
through  the  forearm  while  the  elbow  is  partly  flexed.  If  the  limb  can 
be  fully  extended  abnormal  lateral  mobility  of  the  forearm — adduction 
and  abduction — is  found,  especially  abduction.  The  same  mobility 
exists  when  the  joint  is  more  or  less  flexed,  but  the  observation  cannot 
be  safely  made,  at  least  in  the  young,  because  of  the  difficulty  of  dis- 
tinguishing between  it  and  rotation  of  the  humerus;  full  extension  is 
necessary  for  the  test,  and  this  can  rarely  be  had  except  with  the  aid 
of  general  ansesthesia.  The  relations  of  the  epitrochlea  and  tip  of  the 
olecranon  are  preserved,  and  their  elevation  or  displacement  backward 
with  reference  to  the  external  epicondyle  is  generally  too  slight  to  be 
recognized  through  the  swelling. 

Associated  dislocation  of  the  radius  from  the  capitellum  is  recognized 
by  the  presence  of  its  head  below  and  behind  the  outer  condyle  and  by 
the  marked  displacement  backward  of  the  internal  condyle  and  olecra- 
non which  leaves  the  outer  condyle  and  lower  end  of  the  shaft  as  an 
easily  recognizable  prominence  in  the  flexure  of  the  joint. 

The  main  point  to  be  considered  in  the  treatment  is  the  correction  or 
prevention  of  such  displacement  as  would  seriously  interfere  with  the 
functions  of  the  joint  or  the  appearance  of  the  limb,  notably  the  ascent 
of  the  condyle  by  which  the  axis  of  the  forearm  would  be  directed 


284 


FRACTURES. 


Fig.  183. 


inward  (adduction).  The  fragment  is  too  small  to  be  acted  upon 
directly  by  any  dressing,  and  its  position  must  therefore  be  controlled 
through  the  ulna  to  which  it  is  attached.  Ordinarily  this  can  be  satis- 
factorily done  by  a  fixed  dressing  with  the  elbow  at  a  right  angle,  either 
a  tin  posterior  splint  or,  preferably,  a  moulded  one  or  a  plaster  encase- 
ment. _  The  essential  points  are  that  the  fragment  should  be  kept  well 
down  in  place  while  the  dressing  is  hardening,  if  a  moulded  one  is  used, 
and  that  it  should  not  be  pressed  upward  during  repair  by  the  bandage 
which  supports  the  forearm  ;  this  should  lie  near  the  wrist,  not  under 
the  elbow.  Full  flexion  and  full  extension  of  the  joint,  which  meas- 
urably control  the  position  of  the  fragment  by  the  tension  of  the  pos- 
terior and  anterior  portions  of  the  capsule  respectively,  have  been 
recommended ;  in  each  position  tilting  of  the  fragment  sometimes 
occurs.  Full  flexion  is  a  much  more  convenient  attitude  than  full 
extension,  unless  the  patient  is  kept  in  bed ;  but  it  is  no  more  con- 
venient than  rectangular  flexion  and,  I  think,  gives  no  more  security 
against  displacement.  It  is  usually  desirable  in  fracture  complicated 
by  dislocation  of  the  radius,  in  order  to  oppose  recurrence. 

If  the  fragment  is  rotated  or  tilted  and  cannot  otherwise  be  brought 
into  place,  it  should  be  exposed  by  an  incision ;  advantage  may  be  taken 
of  this  to  fix  the  fragment  in  place  by  periosteal  sutures  or  even  by 
temporary  transfixion  with  a  ])in. 

Immobilization  is  required  for  about  three  weeks,  a  sling  for  another 

week,  and  then  the  limb  abandoned  to  natu- 
ral use  without  forced  passive  motion ;  the 
latter,  for  reasons  given  in  Chapter  VII.,  is 
niOre  likely  to  do  harm  than  good,  for  it 
may  increase  the  irritation  which  provokes 
overgrowth  of  callus.  Even  with  satisfac- 
tory reduction  the  range  of  motion  may  be 
diminished  by  callus  obstructing  the  olecra- 
non or  coronoid  fossa,  and  even  with  con- 
siderable permanent  displacement  the  range 
of  motion  may  be  only  slightly  restricted. 

E.  Fractures  of  the  External  Condyle. 

These  are  much  more  connnou  than  frac- 
tures of  the  internal  condyle,  and  much 
more  frequent  in  the  young  than  in  adults. 
The  cause  is  a  fall  upon  the  hand -while  the 
elbow  is  flexed  or  upon  the  inner  and  pos- 
terior portion  of  the  flexed  elbow,  or  forcible 
adduction  of  forearm ;  in  the  first  the  force  is  transmitted  through  the 
radius  to  the  capitellum  in  a  backward  or  backward  and  upward  direc- 
tion, in  the  second  through  the  olecranon  upward  and  outward  against 
the  outer  slope  of  tiie  trochlea,  and  in  the  third  it  acts  by  avulsion 
through  the  external  lateral  ligament  and  the  muscles  attached  to  the 
condyle.  I  have  found  it  easy  to  produce  the  fracture  by  adduction  of 
the  extended  forearm  in  bodies  of  the  young,  or  by  a  blow  upon  the 


Lines  of  fracture  of  external 
condyle 


FRACTURES  OF   THE  HUMERUS. 


285 


palm  with   the   elbow   flexed  at  a  right  Fig.  184. 

angle  (Fig.  184).  In  one  or  two  cases 
I  have  thought  the  cause  was  a  blow  upon 
the  back  of  the  condyle. 

The  line  of  fracture  runs  obliquely  from 
the  outer  ridge  of  the  humerus  above  the 
epicondyle  do^^^lward  and  inward  into 
the  joint,  ending  usually  in  the  groove  of 
the  trochlea,  coinciding  in  part  at  least 
with  the  epiphyseal  line  so  that  the  frag- 
ment comprises  the  capitellum,  the  outer 
portion  of  the  trochlea,  and  perhaps  the 
epicondyle.  In  the  adult  the  line  seems 
usually  to  extend  somewhat  higher.  As 
the  fragment  remains  attached  to  the 
radius  and  ulna  by  the  lateral  ligament 
and  capsule,  the  displacement  is  usually 
slight  when  the  forearm  is  in  its  proper 
position,  but  there  is  tendency  to  tilting 
(flexion)  of  the  fragment,  and  sometimes 
it  is  markedly  rotated  about  one  or  another      ^^rr'^'t^  ^"^"^T  °^ ,  """^f  °!^ 

."-  (>    T'       1        J  1     condyle  by  a  blow  on  the  palm  of  the 

axis,  SO  tar  m    one  Ot    IvOCher  S    cases  and    hand,  elbow  flexed  at  right  angle. 


Fig.  185. 


Old  fracture  of  external  condyle  of  humerus  with  displace- 
ment downward  and  inward  and  incomplete  dislocation  inward 
of  ulna. 


one  of  mine  that  the  frac- 
tured surface  looked  out- 
ward, and  in  two  of  mine 
upward.  If  the  forearm 
is  abducted  the  fragment 
is  displaced  backward  or 
upward  and  outward;  if 
adducted,  forward  or 
downward.  If  the  elbow 
is  simultaneously  dislo- 
cated backward  or  out- 
ward the  fragment  ac- 
companies the  radius. 

A  late  condition,  some- 
times found,  such  as  that 
sho^^^l  in  Fig.  186,  and 
usually  attributed  to  a 
primary  displacement  left 
uncorrected,  appears  to 
me  to  be  due  more  prob- 
ably to  arrest  of  develop- 
ment at  the  base  of  the 
capitellum.  This  condi- 
tion leads  to  marked  ab- 
duction of  the  forearm 
cubitus  valgus. 


286 


FRACTURES. 


Swelling  appears  first  on  the  outer  side  and  then  becomes  uniform; 
ecchjTuosis  appears  below  the  condyle,  or  on  the  inner  side  if  the 


Fig.  186. 


Fracture  of  external  condyle;  late  result.     Cubitus  valgus.     (Helferich.) 

patient  has  remained  in  bed  with  the  arm  abducted.    Loss  of  function 
is  not  so  marked  as  in  fracture  of  the  internal  condyle;  pain  is  felt  on 

Fig.  187. 


Fracture  of  external  condyle;  patient  eighteen  years  old. 

pressing  the  broken  condyle  against  the  shaft,  inward,  upward,  or 
forward;  also  on  pressure  with  the  tip  of  the  finger  on  the  ridge  close 
above  the  epicondyle.    Abnormal   mobility  appears  as  adduction  of 


FRACTURES  OF   THE  HUMERUS.  287 

the  forearm  (also  painful),  with  less  or  no  abduction,  and  can  sometimes 
be  recognized  by  grasping  the  fragment  between  the  thumb  and  finger 
and  moving  it  backward  and  forward  while  the  shaft  is  firmly  held ;  crepi- 
tus may  be  perceived  at  the  same  time.  If  the  fragment  is  notably 
displaced  the  irregularity  may  be  recognized  by  palpation;  and  if  the 
ulna  is  at  the  same  time  dislocated  backward  from  the  trochlea  the  con- 
dition is  recognized  by  noting  the  common  signs  of  dislocation  on  the 
inner  side — backward  projection  of  the  olecranon,  prominence  of  the 
trochlea  in  the  flexure  of  the  elbow — and  the  position  of  the  fragment 
in  close  relation  with  the  head  of  the  radius  behind  and  above  its 
proper  position.  The  much  rarer  dislocation  outward  could  be  recog- 
nized in  like  manner. 

The  difficulty  in  treatment  lies  more  in  the  reduction  of  displacement, 
if  it  is  marked,  than  in  the  maintenance  of  the  proper  position  if  that 
is  secured.  In  most  cases,  those  without  much  displacement,  immob- 
ilization for  three  weeks  at  a  right  angle  by  a  posterior  moulded 
splint  is  sufficient,  although,  of  course,  pains  must  be  taken  to  make 
reduction  as  complete  as  possible. 

Fig.  188. 


Fracture  of  external  condyle ;  patient  eighteen  years  old. 

When  the  fragment  has  suffered  one  of  the  rarer  displacements  by 
rotation  it  is  generally  impossible  to  restore  it  to  place  without  an 
operation.  In  three  such  cases  I  opened  the  joint  by  an  incision  on  the 
outer  side  and,  with  considerable  difficulty  in  two,  turned  the  fragment 
back  into  place  and  obtained  a  good  result.  Kocher  twice  excised  the 
fragment  under  such  circumstances,  and  reports  a  satisfactory  result ; 
both  were  old  cases,  and  one  of  mine  was  two  months  old. 

In  two  old  cases,  one  of  them  with  displacement  of  the  fragment 
downward  and  inward  and  partial  dislocation  of  the  ulna  inward,  the 
other  with  displacement  upward  and  backward,  I  detached  the  frag- 
ment with  a  chisel  and  brought  it  l)ack  into  place.  Primary  union  ; 
considerable  improvement  in  function. 


288  FRACTURES. 

In  a  few  cases  after  recovery  with  cubitus  valgus  serious  trophic 
and  paretic  changes  due  to  pressure  on  the  ulnar  nerve  have  tardily 
appeared.     (See  Prognosis.) 

F.  Intercondyloid,  T-shaped,  or  Y-shaped  Fractures. 

These  fractures  are  commonly  caused  by  great  violence,  and  conse- 
quently are  often  compound,  either  by  the  direct  action  of  the  violence 
upon  the  skin  or  from  within  outward  by  the  sharp  end  of  one  of  the 
fragments. 

In  many  the  main  line  of  fracture  is  the  same  as  in  supracondyloid 
fracture,  with  an  additional  line  passing  down  into  the  joint  between 
the  condyles ;  in  the  others  the  variations  in  the  form  and  extent  of  the 
fracture  and  the  degree  of  displacement  are  very  great,  the  essential 
features  being  the  separation  of  both  condyles  from  the  shaft  and  from 
each  other,  the  variations  appearing  in  the  number  and  position  of  the 
fragments  and  lines  of  fracture.  When  the  fracture  between  the  con- 
dyles is  a  mere  fissure  the  condyles  remain  together,  and  the  displace- 
ments are  those  of  supracondyloid  fracture;  in  the  other  cases  the 
displacements  are  too  varied  and  irregular  for  classification  and  the 
condyles  may  be  widely  separated  from  each  other,  the  olecranon  pass- 
ing up  between  them. 

Occasionally  the  nerves  or  vessels  crossing  the  front  of  the  joint  are 
torn  or  compressed. 


Fig.  189. 


Fig.  190. 


Intercondyloid  fracture  of  the  humerus. 

(GURLT.) 


Intercondyloid  fracture  of  the  humerus. 
Front  view.      (Gurlt.) 


Symptoms.  The  s>Tnptoms  in  many  cases  are  those  of  supracondy- 
loid fracture  with,  in  addition,  independent  mobility  of  the  condyles 
upon  each  other  and  pain  when  they  are  pressed  together.  In  cases 
with  the  more  varied  displacements  the  deformity  is  great  and  the  inde- 
pendent mobility  of  the  condyles  upon  each  other  and  the  shaft  is 
readily  recognized  if  they  can  be  grasped  through  the  swollen  tissues. 


PRACTURES  OF   THE  HUMERUS.  289 

In  respect  of  treatment  much  that  has  been  said  of  that  of  supra- 
condyloid  fracture  can  be  repeated.  Cases  with  comminution  and  much 
displacement  are  quite  certain  to  result  in  marked  limitation  of  motion 
in  the  joint.  Reduction  by  manipulation  through  the  unbroken  skin 
is  largely  problematical,  and  the  limb  should,  therefore,  be  kept  in  the 
attitude  which  will  be  most  useful  if  stiffness  results.  In  maintaining 
reduction  I  have  been  best  satisfied  with  plaster  splints,  anterior  and 
posterior,  held  snugly  at  and  above  the  condyles  while  they  were  hard- 
ening. Vertical  sus])ension  occasionally  does  well,  especiallv  in  com- 
pound fractures,  but  I  have  never  continued  its  use  for  more  than  about 
ten  days,  resorting  then  to  moulded  splints  with  ihe  elbow  flexed,  and 
with  fresh  reduction  if  necessary.  There  is  of  late  a  distinct  tendency 
toward  operation  in  such  cases  with  the  object  of  suturing  or  pinning 
the  fragments  in  place,  but  it  must  be  remembered  that  an  ideal  restora- 
tion is  far  from  always  producing  a  similar  restoration  of  function. 

In  compound  fractures  it  may  sometimes  be  advisable  to  remove  some 
of  the  smaller  fragments  or  cut  off  sharp  ends ;  and  in  one  case  in 
which  the  fragments  could  not  otherwise  be  held  together  I  transfixed 
them  with  a  long  drill  which  was  left  in  place  for  a  fortnight.  Kocher 
recommends  the  removal  of  the  external  condyle,  on  the  ground  that  it 
facilitates  drainage  and  ensures  a  greater  range  of  motion  without  seri- 
ously diminishing  the  stability  of  the  joint.  Occasionally  it  has  seemed 
advisable  to  remove  both  condyles ;  the  resulting  joint  is  likely  to  be 
troublesomely  loose,  although  not  so  much  so  as  when  the  olecranon 
also  has  been  removed. 

G.  Separation  of  the  Epiphysis. 

To  the  account  of  the  development  of  the  epiphysis  previously  given 
(p.  266)  must  be  added  that  the  views  of  others  differ  therefrom  in 
some  important  details,  and  that  some  of  the  appearances  shown  on 
section  can  be  explained  only  on  the  supposition  that  the  development 
(especially  of  the  trochlea)  differs  widely  in  individuals,  or  (which  seems 
to  me  more  probable)  that  the  sections  have  been  made  in  different 
planes.  The  accounts  which  seem  most  trustworthy  represent  the 
trochlear  portion  of  the  epiphysis  as  remaining  wholly  cartilaginous 
much  longer  than  the  other  portions,  and  as  having  a  concave  upper 
surface  which  steadily  deepens  so  that  before  its  union  with  the  diaph- 
ysis  it  has  become  a  relatively  thin  saucer-like  scale  cap])ing  a  project- 
ing portion  of  the  shaft,  and  is  connected  with  the  capitellum  on  one 
side  and  with  the  epitrochlea  on  the  other  only  by  a  thin  neck.  This 
seems  to  make  the  separation  of  the  entire  epiphysis,  with  or  without 
the  epitrochlea,  in  one  piece  from  the  shaft  very  improbable  except  at 
an  early  age ;  that  it  has  thus  been  separated  is  demonstrated  by  a  few 
specimens,  but  the  diagnosis  in  the  great  majority  of  supposed  cases 
rests  only  upon  doubtful  clinical  evidence.  Moreover,  some  writers 
and  reporters  of  cases  describe  under  this  title  fractures  in  which  the 
line  diverges  widely  into  the  shaft  on  the  inner  side,  and  I  believe  that 
all  the  cases  are  essentially  the  same  as  those  described  above  as  low 
supracondyloid  fractures  in  the  young. 


290  FRACTURES. 

Among  the  specimens  described  are  Lange's/  two  of  Bardenheuer's,^ 
and  two  figured  and  described  by  Poland^  from  the  museums  of  St. 
Mary's  and  St.  Thomas's  hospitals;  in  Lange's  the  patient  was  ten 
years  old,  the  separation  (compound)  was  wholly  through  cartilage, 
and  the:  epicondyles  were  separated  from  the  fragment  and  also 
from  the  shaft;  the  fragment  was  widely  displaced  from  the  shaft 
and  the  bones  of  the  forearm,  but  was  still  attached  to  the  shaft  by  the 
loosened  periosteum.  In  one  of  Bardenheuer's  the  separation  appears  to 
have  been  below  both  epicondyles,  and  the  fragment  was  displaced  back- 
ward and  inward  with  the  forearm ;  in  the  second  the  fragment,  which 
is  not  described  in  detail,  w^as  displaced  backward,  also  preserving  its 
relations  with  the  bones  of  the  forearm.  In  both  of  Poland's  the  separa- 
tion was  wholly  along  cartilage,  the  epicondyles  remaining  attached  to 
the  trochlea  and  capitellum.  A  specimen  apparently  of  pure  cartilag- 
inous separation  was  in  the  Bellevue  Hospital  Museum,  but  has  now 
been  lost. 

The  cause  appears  usually  to  have  been  a  fall  upon  the  elbow  or 
the  outstretched  hand ;  in  Lange's  the  elbow  was  caught  between  an 
elevator  and  a  beam,  and  in  one  of  Poland's  it  was  "jammed  in  a 
gate." 

The  displacement  in  all  the  certain  cases  has  been  great,  and  in  all 
but  Bardenheuer's  the  injury  was  compound.  In  the  alleged  cases 
diagnosticated  without  direct  examination  of  the  fragment  the  displace- 
ment has  been  sometimes  marked,  sometimes  slight,  the  diagnosis  in 
the  former  being  made  by  palpation  of  the  fragment,  in  the  others  upon 
the  abnormal  lateral  and  antero-posterior  mobility  of  the  upper  end  of 
the  forearm  with  fine  crepitus  and  on  the  exclusion  of  other  forms  of 
fracture.  Schiiller  and  Bruns  think  the  injury  more  frequent  than  the 
paucity  of  reported  cases  indicates,  an  opinion  which  must  be  correct 
if  the  low  supracondyloid  fractures  in  the  young  are  included.. 

The  symptoms  and  diagnosis  are  essentially  those  of  low  supracon- 
dyloid fracture  in  the  young.  The  line  of  separation  may  pass  above 
or  below  the  epicondyles  ;  the  essential  diagnostic  feature  (from  dislo- 
cation) is  the  maintenance  of  the  relations  of  the  small  lower  fragment 
with  the  radius  and  ulna ;  and  the  position  of  the  line  of  separation 
along  the  epiphyseal  junction  may  be  indicated  by  cartilaginous  crep- 
itus on  manipulation. 

The  treatment  is  reduction  of  the  displacement  and  immobilization, 
with  special  precautions  against  displacement  inward,  as  in  low  supra- 
condyloid fracture  [q.  v.). 

H.  Fractures  of  the  Articular  Process,  in  Whole  or  in  Part. 

These  include  fractures  of  the  whole  or  part  of  the  capitellum,  of  the 
inner  portion  of  the  trochlea,  and  of  the  capitellum  and  trochlea  together. 

Separation  of  the  entire  articular  process  in  young  children  by  avul- 
sion through  the  anterior  portion  of  the  capsule  in  hyperextension  of 

1  Lange:  Medical  Record,  Jiily,  1880,  p.  48. 

2  Bardenheuer:  Deutsche  Chirurgie,   Lief,   63a,   p.   736. 

'Poland:  "Traumatic  Separation  of  the  Epiphyses,"  London,  1S98. 


FRACTURES  OF  THE  HUMERUS. 


291 


the  elbow,  or  possibly  by  a  fall  upon  the  point  of  the  flexed  elbow,  has 
been  described  by  Kocher  as  part  of  his  group  fractvra  diacondylica. 
I  do  not  see  how  it  is  to  be  distinguished  clinically  (for  he  had  seen  no 
specimen  and  the  .r-rays  are  not  demonstrative),  or  perhaps  even  ana- 
tomically, from  some  forms  of  separation  of  the  epiphysis. 

Fig.  191.  Fig.  192. 


Fracture  of  capitellum. 

Fracture  of  the  capitellum  alone,  in  whole  or  in  part,  has  been  ob- 
served in  a  number  of  cases.  Hahn^  reports  an  old  specimen  in 
which  the  capitellum  had  united  with  the  front  of  the  humerus  after 
displacement  upward  and  rotation.  Kocher  figures  four  specimens 
representing  larger  or  smaller  portions  of  the  capitellum  removed  by 


Fig.  193. 


Fig.  194. 


Fracture  of  capitellum. 


Fracture  of  inner  rim   of  trochlea.      (Tracing  from 
an  imperfect  skiagram.) 


operation  in  fresh  cases;  Figs.  192  and  193  represent  the  largest  and 
smallest.  Steinthal-  reports  a  case  similar  to  Hahn's.  The  capitellum 
was  removed  by  operation,  with  improvement  of  function. 

1  Hahn:  Quoted  by  Gurlt,  loc.  cit.,  p.  801. 

2  Steinthal:  Centralb.  f.  Chir,,  1898,  p.  17. 


202  FRACTURES. 

In  two  of  Kocher's  cases  the  cause  was  violence  exerted  through 
the  radius,  the  elbow  being  flexed,  once  in  a  fall  upon  the  palm  of  the 
hand,  and  once  by  pressure  against  the  palm  while  the  back  of  the 
elbow  rested  against  a  wall;  in  the  other  two  the  injury  was  received 
in  an  eftort  to  raise  or  hold  a  heavy  object,  apparently  with  the  elbow 
partly  flexed.  The  mechanism  in  the  latter  cases  seems  to  me  to  be 
pressure  by  the  head  of  the  radius  upward  against  the  lower  anterior 
portion  of  the  capitellum  under  the  pull  of  the  biceps. 

In  a  personal  case  the  capitellum  was  broken  off  and  the  upper 
posterior  angle  of  the  olecranon  broken  (extra-articular)  by  the  fall  of  a 
heavy  stone.  The  injury  was  compound  and  the  skin  so  contused  that 
it  sloughed ;  the  ensuing  suppuration  led  to  later  excision  of  the  end  of 
the  humerus.  Recovery  with  preservation  of  rotation  of  the  forearm. 
In  another  the  lower .  two-thirds  of  the  capitellmn  was  broken  off, 
but  remained  attached  posteriorly  (Fig.  191).  The  arm  had  been 
cauo^ht  between  a  tugboat  and  a  float.  There  was  a  large  hematoma 
and  a  small  wound  of  the  skin.  I  exposed  the  fracture  and  fas- 
tened the  fragment  in  place  with  periosteal  sutures.  Good  result. 
In  a  third  case  the  line  of  fracture  was  nearly  parallel  to  the  long  axis 
of  the  humerus,  in  a  frontal  plane,  and  the  fragment  had  been  displaced 
upward  and  had  united  with  the  humerus.      I  removed  it. 

In  a  case  similar  to  this  last  one  Dr.  Carleton  Flint  (oral  communica- 
tion) found  the  fragment  united  with  the  humerus  in  such  a  way  that  the 
lower  part  of  its  surface  of  fracture  rested  against  the  side  of  the  head 
of  the  radius  and  had  become  eburnated.  Rotation  was  preserved ; 
flexion  and  extension  almost  entirely  lost.  Removal  of  the  fragment 
restored  motion  between  the  angles  of  45°  and  165°. 

The  local  reaction,  as  evidenced  by  pain,  swelling,  and  loss  of  func- 
tion, is  comparatively  slight  or  tardy  in  appearing ;  in  four  of  eight 
reported  cases  the  fragment  was  displaced  upward  within  the  capsule 
of  the  joint,  in  three  (all  Kocher's)  backward,  lying  between  the  head  of 
the  radius  and  the  olecranon,  where  it  could  be  easily  felt,  in  one 
(FKnt)  outward  and  downward.  Kocher  removed  the  fragment  in  all 
his  cases  and  secured  a  good  result.  Lorenz  ^  reports  2  cases  success- 
fully treated  by  excision  of  the  fragment,  and  quotes  2  others  (Hahn, 
Steinthal)   in  which   the   fragment  was   displaced  upward  beyond  the 

head  of  the  radius.  .  n   i    + 

Fracture  of  the  trocMea  alone  is  very  rare.  Laugier  first  callefl  at- 
tention to  it  in  1 853  in  a  report  of  a  case  in  which  the  diagnosis  rested 
onlv  on  scanty  clinical  evidence.  I  have  had  a  case  in  which  a  frag- 
ment of  the  lower  part  of  the  inner  rim  of  the  trochlea,  about  three- 
fourths  of  an  inch  long,  had  been  broken  off  and  could  be  easily  felt 
beneath  the  epitrochlea!  The  displacement  was.  slight,  so  I  did  not 
excise  the  fracrment,  but  simply  immobilized  the  joint.  The  result  was 
good.  In  another  case.  Fig.  194  with  a  larger  fragment,  the  same 
plan  was  followed  with  a  similar  result. 

1  Lorenz:  Deutsche  Zeitschrift  fiir  Chir.,  vol.  Ixxviii,  p.  531. 


FRACTURES  OF   THE  HUMERUS.  293 

Diagnosis. 

There  is  so  mnch  in  common  in  these  injuries  of  the  lower  end  of  the 
huniertis  that  it  is  well  to  summarize  the  methods  of  examination  and 
the  principles  of  treatment. 

In  most  cases  of  injury  the  diagnosis  at  first  sight  rests  between  frac- 
ture, dislocation,  and  sprain  ;  the  first  two  have  positive  signs  by  which 
they  can  be  affirmatively  recognized,  the  latter  has  its  own  signs,  but 
its  diaguosis  must  be  confirmed  by  exclusion  of  the  other  injuries. 

If  the  case  is  seen  early  the  absence  of  swelling  greatly  facilitates 
examination;  if  excessive  swelling  is  present  it  may  be  diminished  by 
vertical  suspension  of  the  limb  or  by  the  use  of  the  elastic  bandage, 
and  the  fluoroscope  or  the  skiagram  may  give  information  that  cannot 
be  got  at  the  time  by  palpation.  The  region  in  which  swelling  begins, 
or  to  which  it  remains  limited,  is  the  one  which  specially  requires  close 
examination. 

After  the  history  of  the  accident  has  been  obtained — usually  too 
vague  or  uncertain  to  be  of  much  value — and  in  the  absence  of  indi- 
cations pointing  clearly  to  one  or  another  portion  of  the  bone  or  one  or 
another  kind  of  injury,  the  surgeon  seeks  to  place  the  ends  of  his 
thumb,  index-,  and  middle  finger  on  the  two  epicondyles  and  the  tip  of 
the  olecranon  in  order  to  determine  their  relative  positions  and  to  note 
if  their  relations  are  normal  in  such  attitudes  as  he  can  give  to  the 
joint.  This  examination,  if  it  can  be  satisfactorily  made,  should  at 
once  determine  the  presence  or  absence  of  a  dislocation  of  the  ulna, 
and  of  the  radius  if  the  head  of  that  bone  is  next  found. 

If  dislocation  has  thus  been  excluded  and  if  the  patient  is  not  too 
young,  he  next  seeks  the  indications  given  by  pain,  grasping  the  elbow 
with  one  hand  and  the  shaft  of  the  humerus  with  the  other  and  press- 
ino;  the  two  toa^ether  and  then  sidewavs,  with  thumb  and  finders  on  the 
epicondyles,  determining  also  by  the  latter  movement  the  presence 
or  absence  of  abnormal  mobility  of  the  lower  end  upon  the  shaft ;  if 
the'results  suggest  supracondyloid  fracture  confirmation  is  sought  by 
exploration  of  the  condyloid  ridge  for  points  of  pain  and  irregularity 
of  outline,  and  the  shaft  is  traced  downward  to  determine  its  relations 
to  the  condyles.  The  condyles  are  also  pressed  together  to  note  the 
pain  of  a  fissure  running  down  between  them,  or  each  is  grasped  between 
the  thumb  and  fingers  and  the  effort  made  to  move  them  on  each  other. 

The  positive  sign  of  fracture  of  either  condyle  is  its  independent 
mobility,  recognized  by  grasping  it  between  the  thumb  and  fingers  and 
moving  it  backward  and  forward.  Corroborative  evidence,  or  evidence 
that  may  l)e  deemed  sufficient  in  absence  of  independent  mobility,  is 
pain  on  point  pressure  on  the  condyloid  ridge  and  abnormal  abduction 
or  adduction  of  the  forearm  with  pain. 

Fracture  of  the  internal  epicondyle  is  shown  by  its  abnormal  mobility. 

The  positive  evidence  in  every  case  is  the  independent  mobility  of 
the  fragment,  usually  with  crepitus,  anrl  only  when  that  is  unrecog- 
nizable because  of  the  impossibility  of  properly  grasping  the  fragment 
should  the  surgeon  rest  his  diagnosis  upon  other  symptoms.  If  this 
rule  and  that  of  always  determining  the  relative  positions  of  the  ends 


294  FRACTURES. 

of  the  bone  constituting  the  joint  were  followed,  the  disastrous  con- 
founding of  fractures  and  dislocations  would  be  much  less  frequent. 
Anaesthesia  is  indispensable  in  many  cases  for  a  complete  examination. 
The  diagnostic  usefulness  of  the  .-r-ray  in  the  young  is  hampered 
by  the  translucency  of  the  cartilage. 

Treatment. 

The  tendency  to  displacement  except  by  the  unsupported  or  im- 
properly supported  weight  of  the  limb  is  so  slight  that  if  reduction 
can  be  made  a  satisfactory  result  should  be  obtained  in  most  cases, 
the  exceptions  being  those  in  which  the  functions  of  the  joint  are  dimin- 
ished by  obstructive  callus  or  by  peri-articular  thickening.  Conse- 
quently every  effort  should  be  made  to  effect  complete  reduction, 
especially  when  the  fracture  extends  into  the  joint,  even,  if  necessary, 
by  exposure  through  an  incision,  and  then  to  prevent  its  recurrence  by 
so  supporting  the  limb  that  this  cause  of  displacement  may  not  become 
operative.  In  the  great  majority  of  cases  efficient  immobilization  and 
protection  are  afforded  by  moulded  anterior  and  posterior  plaster 
splints,  the  elbow  being  flexed  at  a  right  angle  and  the  limb  supported 
at  the  lorist  by  a  sling.  But  in  the  low  supracondylar  fractures  in  children 
this  attitude  exposes  to  lateral  displacement  by  gravity  and  conse- 
quent marked  cubitus  varus,  and  should  be  guarded  against  as  above 
described.  If  the  sling  is  broader  and  so  placed  as  snugly  to  support 
the  limb  at  the  elbow,  it  may  easily  produce  a  slighter  form  of  cubitus 
varus  in  fracture  of  the  internal  condyle  or  in  the  higher  supracondyloid 
fractures,  by  pressing  the  internal  condyle  or  the  inner  portion  of  the 
lower  fragment  respectively  upward. 

The  stiffness  which  is  found  when  the  splints  are  removed  wall  ordi- 
narily disappear  promptly  under  natural  use.  The  period  can  be  short- 
ened by  systematic  daily  massage,  begun  at  about  the  end  of  the  second 
week.    Bony  anchylosis  is  extremely  rare. 

For  the  details  of  special  cases  which  cannot  well  be  summarized  the 
reader  is  referred  to  the  preceding  sections,  and  for  fracture  of  the 
adjoining  portions  of  the  radius  and  ulna,  to  the  following  chapter. 

Prognosis. 

The  prognosis,  as  indicated  above  in  the  separate  descriptions,  varies 
in  the  different  injuries.  Of  the  larger  groups— supracondyloid, 
external  condyle,  intercondyloid— the  latter  yields  the  highest  pro- 
portion of  defective  results,  and  usually  a  marked  limitation  of  motion. 
In  the  others,  and  especially  in  the  young,  the  result  as  to  function, 
even  if  inferior  as  to  form,  is  often  perfect,  and  limitation  of  motion  if 
present  is  usually  found  only  at  the  extreme  ranges.  This  is  true 
even  of  recovery  with  marked  cubitus  varus;  in  it  function  is  usually 
complete,  but  some  movements  of  the  limb  are  very  ungraceful. 

Since  about  the  year  1900  occasional  cases  of  tardy  paralysis  of  the 


FRACTURES  OF   THE  HUMERUS.  295 

ulnar  nerve  after  fracture  at  the  lower  end  of  the  humerus  have  been 
reported.  Enough  has  appeared  to  show  that  it  is  due  to  pressure  on 
the  nerve  at  the  back  of  the  elbow,  the  result  sometimes  of  change 
in  its  course  because  of  cubitus  valgus,  sometimes  of  cicatricial  bands 
or  of  bony  or  cystic  growths.  A  striking  feature  is  the  long  period 
which  may  elapse  between  the  occurrence  of  the  fracture  and  the 
appearance  of  the  symptoms — 30,  36,  and  39  years.  Marked  relief 
of  symptoms  and  some  complete  cures  have  followed  open  division 
of  the  constricting  bands  or  removal  of  a  gro^^i:h  making  pressure  on 
the  nerve  or  a  supracondylar  osteotomy  to  correct  the  valgus.  For  the 
bibliography,  16  numbers,  and  3  cases,  see  Hunt,  Journal  Am.  Med. 
Assn.,  January  1,  1916,  p.  11,  and  for  7  other  cases  Staffel,  Ztlblatt. 
fiir  chir.,  1914,  p.  1500.  See  also  above,  Section  B,  Frets,  of  Int. 
Epicondyle. 


CHAPTER  XX. 

FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 

In  the  Vicinity  of  the  Elbow-joint:  Olecranon,  coronoid  process,  head  and  neck 
of  radius — Fractures  of  the  Shaft :  Both  bones,  uhia,  radius — In  the  Vicin- 
ity of  the  Wrist:   Of  the  radius,  Colles's,  other  than  Colles's. 

1.  IN  THE  VICINITY  OF  THE  ELBOW- JOINT. 
A.  Fractures  of  the  Olecranon. 

The  frequency  of  fractures  of  the  olecranon  has  been  very  differently 
estimated  by  different  \vriters,  Malgaigne  placing  it  among  the  rarest, 
only  nine  cases  in  a  total  of  more  than  2300  fractures  treated  during 
eleven  years  at  the  Hotel-Dieu.  The  table  in  Chapter  I.  gives  118 
cases  in  a  total  of  14,566  (0.8  per  cent.). 

The  line  of  fracture  may  lie  at  any  point  above  the  base  of  the 
coronoid  process,  crossing  the  bone  transversely  or  obliquely  or  along 
a  V-shaped  line  corresponding  somewhat  to  the  borders  of  the  trian- 
gular subcutaneous  surface  of  the  olecranon.  In  rare  cases  it  is. 
comminuted,  and  sometimes  is  compound.  In  a  very  few  cases  the 
epi]>]iysis  has  been  broken  off  along  the  line  of  the  conjugal  cartilage. 

The  commonest  cause  by  far — 36  out  of  45  cases  collected  by  one  writer 
— is  thought  to  be  a  fall  upon  the  elbow.  The  mechanism,  however,  is 
apparently  not  simply  that  of  fracture  by  direct  violence,  the  bone  is  not 
broken  solely  by  a  force  acting  directly  upon  the  end  of  the  apophysis, 
but  the  contraction  of  the  triceps  must  play  an  important  part  in  it. 
Among  the  reasons  for  this  belief  are  the  usual  absence  of  the  signs  of 
direct  violence  upon  the  surface  of  the  region  sufficient  to  have  caused 
the  fracture,  and  the  impossibility  of  producing  similar  fractures  upon 
the  cadaver  by  this  means.  When  the  fractui^e  is  produced  experi- 
mentally by  direct  violence,  by  a  blow  witii  a  blunt  object,  the  bone  is 
not  broken  cleanly  and  transversely  at  its  narrowest  part,  as  is  the  case 
in  most  fractures  observed  clinically,  but  it  is  crushed  and  split  into 
several  pieces.  The  explanation  that  seems  most  plausible  is  that  a 
sudden  change  is  effected  in  the  position  of  the  forearm  by  the  fall 
when  the  muscles  are  all  tense.  The  man  falls  with  his  elbow  partly 
bent,  and  all  his  muscles  rigid  with  the  effort  to  save  himself;  his  out- 
stretched hand  or  the  back  of  his  forearm  encounters  some  solid  object, 
and  the  flexion  of  the  limb  is  suddenly  and  violently  increased,  while 
the  olecranon  is  held  immovable  by  the  triceps.  The  consequence  is 
that  the  ulna  is  bent  about  the  elbow,  and  breaks  at  the  weakest  part 
of  the  olecranon  if  the  violence  is  received  near  the  elbow,  or,  perhaps, 
at  some  part  of  its  much  thinner  shaft  if  the  violence  is  received  upon 
the  hand. 

( 296 ) 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM, 


297 


Occasionally  the  olecranon  has  been  broken  in  an  attempt  to  reduce 
an  old  dislocation  or  to  mobilize  a  stiff  elbow  ;  and  it  has  been  alleged 
that  a  blow  upon  the  back  of  the  ulna  near  the  elbow  can  break  or 
crack  the  olecranon  from  the  articular  surface  outward. 

Muscular  action,  contraction  of  the  triceps,  appears  to  be  an  occa- 
sional cause,  as  in  throwing  a  ball  or  vigorously  pushing  with  the  elboAV 
partly  flexed.  In  such  fractures  the  fragment  torn  ofl"  is  small,  little 
more  than  the  cortical  layer  of  the  summit  of  the  process  to  which  the 
triceps  is  principally  attached  ;  in  other  cases  the  line  of  fracture  lies 
usually  at  the  narrowest  part  of  the  process,  directly  under  the  centre 
of  the  sigmoid  fossa,  that  which  is  called  by  some  the  centre,  by  others 
the  base,  of  the  olecranon. 

Fig.  195. 


Fracture  of  olecranon,    x-ray  tracing. 
Fig.  196. 


Fracture  of  olecranon,    a-ray  tracing. 

Another  variety  of  fracture,  partial  or  complete,  and  produced  from 
within  outward,  has  been  spoken  of  by  different  writers  as  theoretically 
])ossible,  but  has  only  recently  been  observed  and  described  clinically. 
Pingaud  '  produced  it  experimentally  in  the  effort  to  dislocate  the  ulna 
backward  by  over-extension  (extension  beyond  the  straight  line)  of  the 
forearm.  The  end  of  the  olecranon  is  pressed  against  the  humerus, 
the  lateral  ligaments  resist  the  movement,  and  the  prolongation  of  the 
effort  results  in  fracture  of  the  olecranon  or,  much  more  commonly,  of 
the  thinner  and  weaker  shaft  of  the  ulna.  Quintin "  reports  three 
cases  of  incomplete  fracture  of  the  olecranon  ;  the  surface  articulating 
with  the  humerus  was  broken,  the  dorsal  portion  was  unbroken  ;   in  all 

'  Pingaud  :  Diet.  Encylopedique,  art.  Coude,  pp.  !il7  and  631. 

2  Quintin  :  Beitrag  zur  Lehre  von  den  Briichen  des  Olekranon,  Bonn,  1881,  Abstract  in 
Centrall)latt  fiir  Chirurgie,  1881,  p.  763, 

2: 


298  FRACTURES. 

the  swelling  was  moderate,  the  pain  severe,  flexion  and  extension  com- 
plete but  slow.  In  the  first  case,  seen  a  week  after  the  accident,  a  small 
prominence  could  be  felt  on  the  side  of  the  olecranon,  and  behind  it 
was  a  notch ;  the  upper  end  could  be  sprung  back  a  little.  In  the 
second  case  a  short  shallow  groove  could  be  felt  on  the  outer  side  of 
the  olecranon,  at  its  base ;  and  in  the  third  the  olecranon  could  also  be 
sprung.  Quintin  thinks  this  fracture  is  frequently  overlooked  and 
treated  as  a  simple  contusion.  The  symptoms  in  the  three  cases 
described  will,  perhaps,  hardly  be  considered  entirely  demonstrative,  in 
the  absence  of  corroborative  testimony  of  direct  examination,  of  a 
recent  fracture;  and,  indeed,  it  is  only  by  assuming  that  the  injury  is 
a  common  one  and  has  heretofore  always  been  overlooked  that  its 
occurrence  three  times  during  a  short  period  in  the  experience  of  one 
observer  can  seem  probable. 

Symptoms.  The  symptoms  of  the  fracture  are  pain,  swelling,  dis- 
placement, and  mobility  of  the  upper  fragment,  sometimes  crepitus, 
and  loss  of  power,  especially  of  active  extension. 

As  the  result,  apparently,  of  theoretical  considerations,  and  of  what 
has  been  observed  in  exceptional  cases,  the  tendency  to  displacement 
upward  of  the  fragment  by  the  contraction  of  the  triceps  has  been 
somewhat  overstated.  This  action  of  the  muscle  is  greatly  restricted 
by  the  lateral  aponeurotic  attachments  and  ligaments,  and  by  the  exten- 
sion of  the  insertion  of  the  triceps  along  the  lateral  and  posterior  aspects 
of  the  olecranon,  all  of  which  must  be  ruptured  before  the  fragments 
can  be  widely  separated  and  the  upper  one  drawn  liigh  up.  In  a  dis- 
cussion in  the  Societe  de  Chirurgie  which  followed  the  presentation  by 
Bardinet  of  a  paper  upon  this  subject,  Robert,  Richert,  and  Gosselin 
testified  to  the  tistial  absence  of  separation  in  their  experience,  and 
similar  testimony  has  since  been  furnished  in  abundance. 

If  the  thick  periosteum  and  tendinous  attachments  on  the  sides  and 
back  of  tlie  olecranon  are  torn,  nothing  remains  to  hold  the  fragments 
together,  and  separation  may  be  eifected  either  by  the  contraction  of 
the  triceps,  drawing  the  upper  fragment  away  from  the  shaft  of  the 
bone,  or  by  flexion  of  the  forearm,  drawing  the  bone  away  from  the 
fragment.  In  either  case  coaptation  is  effected  by  extending,  straight- 
ening, the  forearm  upon  the  arm,  because  the  triceps  cannot  draw  the 
fragment  above  the  position  which  it  takes  in  complete  extension 
unless  the  ligaments  which  bind  it  to  the  humerus  are  torn,  and  this  is 
a  complication  which  apparently  happens  very  rarely. 

In  old  ununited  cases  the  gradual  retraction  of  the  triceps  draws 
the  fragment  upward,  but  not  even  in  such  has  it  risen  above  the  ole- 
cranon fossa. 

Another  displacement,  one  that  is  important  because  of  the  danger 
that  the  skin  may  be  broken  by  the  pressure  to  which  it  leads,  is  an 
angular  one  observed  in  a  few  cases  when  the  line  of  fracture  has  been 
near  the  base  of  the  coronoid  process,  and  especially  when  its  direction 
has  been  obliquely  downward  and  backward  and  the  upper  fragment 
has  ended  in  a  sharp  lower  edge  or  point. 

Coincident  dislocation  of  the  radius  and  ulna  forward  is  occasionally 
seen.     (See  Chapter  XLV. 


FRACTURES   OF  THE  BONES   OF  THE  FOREARM.  299 

Mobility  of  the  fragment  is  recognized  by  grasping  it  between  the 
thumb  and  finger  and  moving  it  laterally,  or  by  flexing  the  forearm 
gently  while  the  finger  is  pressed  against  the  groove  or  crack  left  by 
the  separation  when  it  is  slight.  If  the  fragments  are  brought  together 
by  extending  the  forearm  or  drawing  the  upper  fragment  down,  crepi- 
tus can  be  felt. 

If  the  swelling  is  sufficient  to  prevent  recognition  of  these  objective 
signs,  the  fracture  may  be  suspected  from  the  history  of  the  case  and 
the  loss  or  marked  diminution  of  the  power  of  active  extension. 

Repair.  It  is  very  important,  with  reference  both  to  the  treatment 
and  prognosis,  that  the  character  and  extent  of  the  displacement 
should  be  known.  As  a  rule,  union  takes  place,  but  it  is  fibrous,  not 
bony  ;  and  the  restoration  of  function  depends  in  a  measure  upon  the 
length  of  the  fibrous  band.  I  say  "in  a  measure,"  for  experience 
has  shown  in  not  a  few  cases  that  there  may  be  excellent  control  over 
the  limb  even  with  a  long  fibrous  band  between  the  two  fragments. 
The  disability  sometimes  observed  under  the  opposing  conditions, 
limitation  of  motion  when  the  band  is  short,  is  due  to  adhesions 
between  the  fragment  and  the  humerus,  or  to  change  in  the  flexibility 
and  length  of  the  capsular  bands.  The  process  of  repair  involves  two 
dangers  :  defective  union  or  failure  of  union  between  the  fragments, 
and  the  formation  of  intra-articular  bands  or  changes  in  the  articular 
and  peri-articular  tissues. 

Instances  of  bony  union  do  exist.  Malgaigne  figures  and  describes 
one  in  his  Atlas  (Plate  XXIV.,  fig.  2),  which,  however,  differs 
notably  from  the  ordinary  fracture,  the  line  having  run  so  obliquely 
as  to  bring  away  with  the  olecranon  a  lateral  half  of  the  coronoid  pro- 
cess. Many  instances  of  union  with  very  slight  separation,  if  any, 
and  apparently  bony,  have  been  reported,  but  in  only  a  few  has  the 
character  of  the  union  been  established  by  autopsy.  Gurlt  ^  describes 
and  pictures  two  :  one,  a  fracture  half  an  inch  from  the  apex  of  the 
process,  united  with  slight  displacement  of  the  fragment  upward  and 
only  a  small  amount  of  callus  on  the  outer  side ;  the  line  of  fracture 
IS  partly   visible   upon   the  surface 

of  section,  and  complete  extension  Fig.  197. 

of  the  joint  is  prevented  by  an  over- 
growth of  bone  at  the  apex.  The 
other  is  an  oblique  fracture  (Fig. 
197),  and  has  united  so  completely 
that  the  only  sign  of  it  is  "  a  shal- 
low groove  on  the  under  surface  of 

the     olecranon      running     obliquely    Fractureofolecranon;  bony  union.  (Gurlt.) 

backward   from   the    radial    to    the 

ulnar  side.  The  articular  cartilage  is  lacking  in  part,  and  the  callus 
consequently  visible."  Apparently  bony  union  is  more  probable  when 
the  fracture  is  oblique. 

The  length  of  the  fibrous  band  varies  within  very  wide  limits.  Fig. 
198,  taken  from  Malgaigne,  represents  a  comparatively  short  band 
and   one   that  presents  another  peculiarity  in  that  it  consists  of  two 

1  Gurlt:  Loc.  cit.,  vol.  i.  p.  41,  Fig.  9,  tuul  p.  310,  Fig.  121. 


300 


FRACTURES. 


lateral  bands  with  a  central  interval  or  gap.  This  is  by  far  the  most 
common  mode  of  reunion,  and  although  several  cases  have  been 
reported  in  which  the  patient  appeared  to  have  regained  full  use  of  the 

Fig.  198. 


Fracture  of  the  olecranon  ;  fibrous  union.     (Malgaigne.) 

arm,  notwithstanding  fibrous  union  with  separation  to  the  extent  of 
half  an  inch  more,  yet  actual  deficiency  in  the  power  of  active  exten- 
sion of  the  forearm  is  to  be  regarded  as  a  frequent  result  of  fibrous 
union,  and  its  degree  will  vary  directly  with  the  length  of  the  band. 
The  disability  may  be  unnoticed  by  others,  and  its  consequences  may 
be  avoided  or  dimiuished  by  care  in  the  u.se  of  the  arm,  by  avoidance 
of  positions  and  movements  which  require  the  especial  action  of  the 

Fig.  199. 


^^^Pi.^ 


Ununited  fracture  of  the  olecranon,    a,  the  upper  fragment;  b,  the  external  condyle. 

triceps,  but  it  exists  and  can  be  readily  demonstrated.  Malgaigue 
describes  a  case  in  which  the  fragment  apparently  had  not  reunited 
with  the  shaft,  and  yet  the  patient  could  use  the  limb  actively,  and 
even  handle  a  s^vord  or  a  foil.  On  examiuation  it  was  found,  how- 
ever, tliat  the  vigor  and  strength  of  the  arm  depended  largely  upon  its 
position,  being  greatest  when  the  hand  was  supinated  and  the  arm 
dependent,  and  disappearing  almost  entirely  when  the  arm  was  raised 
above  the  horizontal  line. 

Failure  of  union,  as  in  the  case  just  mentioned,  is  not  very  uncom- 
mon ;  the  upper  fragment  may  remain  freely  movable,  or  it  may  become 
adlierent  to  the  humerus.     In  a  case  of  the  latter  condition  which  came 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM.  301 

under  my  observation  thirty-five  years  after  the  accident  (Fig.  199) 
the  forearm  could  be  completely  flexed  and  could  be  extended  to  135 
degrees,  the  force  of  extension  being  very  feeble. 

In  the  majority  of  cases  union  takes  place  with  but  little  separation 
and  with  full  restoration  of  function,  so  far  at  least  as  power  is  con- 
cerned, although  extension  is  often  incomplete. 

A  still  more  unfortunate  result,  anchylosis  of  the  joint,  has  followed 
in  a  small  number  of  cases.  Malgaigne  quotes  from  Camper  and 
Trioen  an  anatomical  specimen  of  bony  fusion,  and  although  it  is  not 
specifically  asserted  that  the  union  was  between  the  ulna  and  the 
humerus,  this  seems  probable  from  the  context.  Thierry,  according 
to  Pingaud,  reported  two  cases  of  articular  rigidity  that  had  lasted,  the 
one  for  six  months,  the  other  for  a  year,  in  spite  of  the  most  persistent 
efforts  to  overcome  it.  I  have  seen  a  case  in  which  the  joint  was  stiff 
in  full  extension  after  wiring  of  the  fragments,  although  the  operation- 
wound  had  healed  without  suppuration. 

The  course  of  the  fracture  is  ordinarily  very  simple  and  uncompli- 
cated ;  the  swelling  subsides  promptly  and  union  takes  place  in  from 
three  to  four  weeks. 

Treatment,  Discussion  concerning  the  proper  treatment  of  fracture 
of  the  olecranon  has  turned  mainly  upon  the  position  to  be  given  to 
the  limb,  some  favoring  the  extended  position  in  order  to  secure  closer 
union  of  the  ligaments,  others  recommending  flexion,  either  because 
they  did  not  fear  separation  of  the  fragments  and  sought  the  position 
that  could  be  kept  with  the  least  discomfort,  or  because  they  feared 
anchylosis  and  wished  to  have  the  limb  in  the  most  fevorable  position 
if  it  should  occur.  It  is  evident  from  the  facts  that  have  been  already 
stated  that  neither  the  first  nor  the  third  reason  is  sufficient  to  establish 
a  rule  of  practice  to  be  followed  in  all  cases.  The  probability  of  the 
occurrence  of  anchylosis  after  simple  fracture  is  very  small,  so  small 
that  it  ought  not  to  be  weighed  against  that  of  non-union  when  the 
fragments  are  separated  rather  widely.  On  the  other  hand,  the  sepa- 
ration at  first  is  so  slight  in  many  cases  and  the  extended  position  so 
unnecessary  to  overcome  it  that  if  partial  flexion  is  more  comfortable 
to  the  patient,  if  it  makes  the  restraint  less  irksome,  it  should  not  be 
denied  him.  Furthermore,  there  appears  to  be  danger  of  tw^o  displace- 
ments in  complete  extension  :  if  the  fracture  is  at  or  near  the  base  of 
the  process  the  ulna  can  be  readily  dislocated  forward  ;  and  secondly, 
effusion  into  the  joint  or  swelling  of  the  capsule  may  prevent  the  tip  of 
the  olecranon  from  sinking  into  the  olecranon  fossa  to  the  usual  depth, 
and  under  such  circumstances  complete  extension  of  the  forearm  would 
cause  a  tilting,  an  angular  displacement  of  this  fragment.  This  latter 
point  has  been  made  by  several  writers  upon  theoretical  grounds  alone, 
but,  although  it  seems  plausible,  no  confirmatory  observation  has  been 
made,  so  far  as  I  know. 

The  aim  of  treatment  should  be  to  secure  bony  union  if  possible,  and, 
failing  that,  close  fibrous  union,  and  this  consideration  will  regulate  the 
position  to  be  given  to  the  arm.  If  there  is  wide  separation  which 
increases  as  the  elbow  is  flexed,  if  the  fragments  cannot  be  brought 
well  together   except  by  extending  the  forearm,   that  position   must 


302  FRACTURES. 

be  taken  and  kept  until  consolidation  is  well  advanced.  If,  on 
the  other  hand,  the  separation  is  slight  and  the  upper  fragment 
follows  the  movements  of  the  lower,  if  they  can  be  easily  brought  to- 
gether and  kept  so  by  moderate  traction  u])()n  the  upper  one,  the 
patient  may  be  safely  allowed  the  comfort  of  the  partly  flexed  posi- 
tion. 

Apparently  it  is  not  often  necessary  to  take  especial  measures  to  draw 
the  upper  fragment  down  to  the  lower  one,  and  even  when  there  is  con- 
siderable separation  between  them  in  the  flexed  position  it  is  usually 
stifficient  simply  to  extend  the  elbow.  Some  methods  of  treatment, 
however,  have  been  designed  with  the  especial  intention  of  drawing 
the  fragment  down,  and  it  has  been  sought  to  accomplish  this  by  figure- 
of-eight  bandages  passing  above  and  below  the  fragment  and  crossing  in 
front  of  the  elbow,  or  by  circular  bands  about  the  arm  drawn  together 
by  longitudinal  ones.  In  others,  strips  of  adhesive  plaster  have  been 
applied  to  the  skin  above  the  olecranon,  drawn  down  sntigly,  and  fast- 
ened to  the  skin  of  the  forearm  or  to  the  splints  ;  sometimes  the  plaster 
is  cut  in  the  form  of  a  U,  the  olecranon  lying  in  the  angle  and  the  two 
sides  passing  along  the  forearm. 

Metal  hooks  similar  to  those  used  in  fracture  of  the  patella  have 
also  been  used  here  sticcessfuUy.  although  not  frequently.  I  do  not 
know  when  or  by  whom  they  were  first  employed,  but  Busch  recom- 
mended them  in  1864,  and  Pingaud^  speaks  of  the  use  of  a  similar 
method  "a  very  long  time  ago"  by  Prof.  Eigaud,  of  Strasburg.  It 
is  sufficient  that  the  hook  should  have  but  a  single  point  at  the  upper 
end,  and  at  the  other  end  should  be  made  fast  to  a  gypsum  bandage 
covering  the  arm  and  forearm  and  provided  Avith  a  large  fenestra 
behind  the  elbow. 

The  best  splint  is  an  anterior  one  made  fast  to  the  limb  by  a  roller 
bandage  or  a  fenestrated  gypsum  bandage.  It  is  not  worth  while,  I 
think,  to  try  to  force  the  upper  fragment  down  by  turns  of  a  roller 
bandage,  because  this  can  be  done  much  more  effectively  when  necessary 
bv  adhesive  plaster  or  hooks.  In  short,  the  treatment  to  be  recom- 
rnended  is  as  follows  :  If  the  separation  is  slight  and  is  not  increased 
by  the  flexed  position  it  is  only  necessary  to  immobilize  the  limb  with 
the  forearm  slightly  flexed,  about  midway  between  complete  extension 
and  flexion  at  a  right  angle,  and  for  this  purpose  an  anterior  splint  of 
wood  or  of  plaster  of  Paris  is  sufficient  and  convenient.  If  the  frag- 
ment shows  anv  tendency  to  be  drawn  up  it  should  be  secured  with 
adhesive  plaster.  If,  on  the  other  hand,  there  is  notable  separation, 
and  if  the  separation  is  increased  by  flexion  of  the  forearm,  the  exten- 
sion should  be  complete  enough  to  bring  the  fragments  together,  and  it 
should  be  aided  by  adhesive  plaster  or  hooks.  The  fenestrated  gypsum 
bandage  seems  to  be  the  one  best  fitted  for  this  purpose,  and  the  fenes- 
tra should  lie  large  enough  and  so  placed  as  to  permit  inspection  of  the 
seat  of  fracture.  If  Malgaigne's  hooks  are  used  in  connection  with  it 
one  hook  or  pair  of  hooks  should  be  forced  through  the  tendon  of  the 
triceps  down  to  the  bone,  and  the  other  pair  fixed  to  the  gypsum 
bandasre  below  the  fenestra.     In  one  of  three  cases  recorded  bv  Quin- 

^  Pingaud  :  Diet  Encyclopedique.  art.  Coade.  p.  639  (1878J. 


FRACTURES   OF  THE  BONES  OF  THE  FOREARM.  303 

tin/   the  hooks   remained   in   place   four   weeks   without   causing  any 
inflammatorv  symptoms. 

If  the  patient  is  rheumatic,  or  if  the  reaction  has  been  severe  and 
prolonged  and  anchylosis  is  feared,  it  is  well  to  change  the  degree  of 
flexion  slightly  from  time  to  time  after  the  pain  aud  inflammation  have 
disappeared  ;  and  if  the  tendency  to  separation  is  slight  this  change  of 
position  may  be  begun  quite  early.  It  mu.st  be  done  very  gently  and 
cautiously,  and  the  upper  fragment  must  be  supported  by  the  finger  in 
order  that  the  adhesions  may  not  be  ruptured.  In  a  case  reported  by 
Pingaud,^  the  callus  was  broken  by  this  attempt  at  passive  motion  ; 
and  as  the  surgeon  did  not  dare  to  immobilize  the  joint  again  for  three 
or  four  weeks  he  applied  a  ]ilaster  bandage  to  the  forearm,  and  used  it 
as  the  support  for  a  pair  of  Malgaigne's  hooks  by  which  he  was  enabled 
to  keep  the  fragment  perfectly  in  place,  and  at  the  same  time  to  move 
the  elbow  as  much  as  he  wished. 

If  the  joint  is  much  distended  by  blood  and  synovia  removal  by 
aspiration   will   make    approximation   easier. 

Resort  to  operation,  suture  or  plating,  is  not  infrequent.  I  have 
always  found  suturing  of  the  fibroperiosteum  sufRcient,  or  a  mediate 
suture  passing  through  the  tendon  of  the  triceps  and  a  hole  drilled 
transversely  through  the  bone  below  the  fracture.  A  direct  metallic 
suture  across  the  fracture  should,  in  my  opinion,  not  be  used. 

In  a  few  cases  of  fibrous  union  with  much  separation  and  consequent 
disability  operative  measures,  according  to  some  of  the  various  plans 
mentioned  in  Chapter  VIII,  have  been  undertaken  to  obtain  closer 
union. 

Separation  of  the  Epiphysis,  Ossification  of  the  epiphysis  begins  in 
the  ninth  or  tenth  year  and  is  complete  by  the  fifteenth  ;  bony  union 
with  the  rest  of  the  olecranon  takes  place  about  the  seventeenth  vear. 
At  the  tenth  year  the  epiphysis  constitutes  about  one-third  of  the 
olecranon,  and  the  proportion  diminishes  as  age  advances. 

The  cases  of  separation  are  rare.  Apparently  it  is  most  likely  to  be 
produced  by  extreme  flexion  of  the  elbow,  through  the  pull  of  the 
stretched  triceps,  and  in  the  older  and  more  muscular  by  active  con- 
traction of  the  triceps  ;  possibly  also  by  the  other  causes  of  fracture  of 
the  olecranon. 

Prol)al)ly  a  sleeve  of  periosteum  from  the  adjoining  portion  of  the 
bone  remains  attached  to  the  e])iphysis,  as  in  other  e])iphyseal  separa- 
tions, and  if  the  displacement  is  not  such  as  to  permit  this  sleeve  to 
drop  in  between  the  fragments  it  will  aid  in  establishing  reunion.  If 
it  should  fall  in,  an  open  operation  would  probably  be  needed  to  effect 
its  readjustment.  Otherwise  the  treatment  is  on  the  same  principle  as 
that  of  fracture. 

1  Quintin:  Centralblatt  fiir  Chirurgie,    1881,   p.   764. 

2  Pingaud:  Gazette  Hebdomadaire,  May  21,  1875. 


304 


PRA'CTURSS. 


B.   Fractures  of  the  Coronoid  Process.^ 

This  fracture,  the  frequency  of  which  has  been  much  disputed,  is 
unquestionably  very  rare  except  as  a  complication  of  dislocation  of  the 
ulna  backward. 

So  far  as  can  be  inferred  from  the  few  detailed  descriptions  of  speci- 
mens the  line  of  fracture  crosses  the  process  transversely  or  somewhat 
obliquely  at  about  one-fourth  of  an  inch  below  its  apex,  and  may 
reunite  with  a  close  bony  union  or  by  a  fibrous  band.  When  the 
union  is  close  and  bony  there  may  be  a  somewhat  exuberant  callus 
upon  the  anterior  aspect  of  the  process,  due  probably  to  the  stripping 
up  of  the  periosteum  or  tendon. 

Tile  mechanism  in  the  great  majority  of  cases  is  by  indirect  violence 
exerted  in  such  a  way  as  to  cause  dislocation  of  the  joint  backward  and 
to  break  oif  the  point  of  the  process  as  it  is  forced  past  the  trochlea, 


Fig.  200. 


Fig.  201. 


Fracture  of  the  coronuid  process  of  the  right  ulna. 
United  with  exuberant  callus  on  the  anterior  surface, 
line  of  fracture  still  visible  on  the  articular  surface. 
a,  a  small  fragment  broken  from  the  articular  border 
of  the  olecranon  and  reunited.    (Gurlt.) 


Fracture  of  the  coronoid  process  and 
the  head  of  the  radius.   (Bryant.) 


and  in  such  cases  there  is  also  sometimes  fracture  of  the  anterior  por- 
tion of  the  head  of  the  radius.  In  one  case  mentioned  by  Lotzbeck^ 
the  process  appeared  to  have  been  broken  off  by  direct  violence ;  a 
soldier  was  struck  in  the  elbow  by  a  piece  of  a  shell  which  caused  a 
severe  contusion  but  no  open  w^ound.  Two  months  afterward  the  coro- 
noid process  could  be  felt  as  a  movable  body,  and  by  pressing  it  down 
it  could  be  made  to  rub  against  the  ulna  with  a  creaking  sound.  Acu- 
puncture proved  the  supposed  fragment  to  be  a  hard  solid  body.  In 
another  case,  that  of  a  boy  fourteen  years  old,  the  process  was  broken  off 
by  extreme  flexion  of  the  elbow.  A  somewhat  similar  personal  expe- 
rience may  be  mentioned  as  corroborative  of  this  mechanism  to  a  cer- 
tain extent.  I  excised  an  elbow  for  suppurative  disease  of  the  joint, 
using  Ollier's  postero-lateral  incision.  In  order  to  facilitate  the  clean- 
ing of  the  external  condyle,  and  before  the  olecranon  had  been  touched, 
I  asked  the  assistant  to  flex  the  elbow;  he  did  so  with  some  force,  and 


1  The  references  to  the  specimens  in  the  first  edition  are:  Cooper,  Fractures  and  Dis- 
locations, p.  411;  S.  Cooper  and  Gibson,  quoted  by  Hamilton;  Velpeau,  Annales  de  la 
Chir.,  1843,  vol.  ix,  p.  98;  Berard,  Diet,  de  Med.,  en  30  vols.,  art.  Coude,  p.  228;  Gurlt, 
vol.  i,  p.  41;  Bryant's  Surg.,  3d  Am.  ed.,  vol.  i,  p.  837;  two  in  Holmes's  System,  Am.  ed., 
vol.  i,  pp.  859,  860;  Annandale,  Medical  Times  and  Gazette,  1875,  vol.  i,  p.  576,  and 
Edinburgh  Medical  Journal,  February,  1885,  p.  681.  For  a  personal  case  see  the  following 
section.  Fractures  of  the  Head  and  Neck  of  the  Radius. 

2  Lotzbeck:  Schmidt's  Jahrbuch,  1866,  vol.  cxxix,  p.  134. 


FRACTURES  OF   THE  BONES  OF   THE  FOREARM.         "305 

felt  something  snap.  About  half  an  inch  of  the  coronoid  process  was 
found  to  have  been  broken  oif.  It  seemed,  however,  to  be  unusually 
long  and  prominent,  possibly  by  ossification  of  the  attached  capsule  in 
consequence  of  the  prolonged  inflammation. 

As  regards  experiment  upon  the  cadaver  we  have  the  assertion  of 
Malo-aigne,^  that  in  producing  dislocations  backward  he  broke  off  the 
end  ''of  the  coronoid  process  quite  frequently,  and  the  more  detailed 
results  of  Lotzbeck  who  fixed  the  elbow  in  a  slightly  flexed  position  by 
means  of  a  gypsum  bandage  and  then  by  striking  upon  the  ])alm  of 
the    hand    broke  the    coronoid    process    five  times    in    ten  attempts. 

Fig.  202. 


Fracture  of  coronoirl  process  at  and  beyond  its  base.     (U.  S.  Army  Med.  Museum.7 

Schwenk  [Ztlblatt  f.  Chir.,  1908,  p.  976)  reports  a  similar  case  without 
dislocation,  confirmed  by  the  a;-rays. 

The  mechanism  of  this  production  and  the  anatomical  relations  of 
the  process  explain  the  union  with  slight  displacement  shown  in  some 
of  the  specimens  and  the  difficulty  of  diagnosis  during  life.  The  ten- 
don of  the  brachialis  anticus  is  inserted  not  upon  the  top  of  the  process 
but  upon  its  anterior  aspect  and  base,  and  the  articular  capsule  is 
attached  all  along  its  edge.  When  it  is  broken  off"  by  being  forced 
backward  against  the  trochlea  its  connection  with  the  ulna  is  preserved 
in  front  by  the  tough  attachments  of  the  tendon,  and  therefore  instead 
of  being  displaced  bodily  along  the  anterior  aspect  of  the  bone  it  is 
probably  only  tilted  forward.  Its  vitality  is  assured  in  any  case  by 
its  connection  with  the  capsule,  and  when  the  dislocation  is  reduced 
the  fragment  is  held  exactly  in  place  by  the  tendon  of  the  brachialis 
anticus  in  front  and  the  humerus  behind. 

The  symptoms  and  the  means  of  diagnosis,  in  view  of  the  uncer- 
tainty of  the  diagnosis  in  the  supposed  cases,  cannot  be  positively 
described ;  those  wliich  have  been  deemed  sufficient  are  :  dislocation 
backward,  easy  reduction,  great  tendency  to  recurrence,  possibly  crepi- 
tus, and  the  presence  of  a  hard  movable  body  in  front  of  the  elbow  in 
the  line  of  the  tendon  of  the  brachialis  anticus.  In  a  personal  case 
the  supposed  fragment  could  be  readily  grasped  between  the  thumb 
and  finger  and  moved  freely  to  and  fro. 

Treatment.  The  treatment  consists  in  immobilization  of  the  joint 
flexed  to  a  right  angle  or  beyond.    The  degree  of  flexion  and  the  com- 

'  Malgaigne:  Luxations,  p.  634. 


306  FRACTURES. 

pleteness  of  the  immobilization  may  vary  with,  the  tendency  to  dis- 
placement. If  the  latter  is  great,  experience  has  shown  that  it  is  best 
opposed  by  increasiug  the  flexion  ;  and,  of  course,  complete  immobil- 
ization gives  additional  security.  The  immobilization  should  be  main- 
tained as  long  as  the  tendency  to  dislocation  exists ;  when  that  ceases 
the  splint  becomes  unnecessary,  and  the  only  indication  then  is  to  main- 
tain sufficient  flexion  to  favor  prompt  and  close  union. 

C.  Fractures  of  the  Head  of  the  Radius. 

Our  knowledge  of  this  variety  of  fracture  is  drawn  from  about  a 
score  of  specimens,  old  or  recent,  and  a  constantly  increasing  number 
of  clinical  cases  supported  by  skiagrams.  It  has  recently  been  studied 
by  Thomas^  in  a  paper  admirable  alike  for  its  thoroughness  of  research 
and  its  soberness  of  judgment.  Apparently  the  injury  occurs  quite 
frequently  ;  Thomas  collected  48  cases  and  found  evidence  of  55  others 
in  skiagrams  taken  in  Philadelphia.  The  line  of  fracture  may  sepa- 
rate a  small  portion  of  the  head,  about  one-third,  or  a  much  larger 
portion  passing  down  through  the  neck,  or  may  split  the  head  into  two 
or  more  pieces  and  separate  all  of  them  from  the  shaft.  Usually  the 
fragments  retain  connection  with  the  periosteum  of  the  neck. 

Cause.  The  cause  may  be  a  blow  upon  the  head  of  the  bone  (Stim- 
son,  Cheyne,  Delorme),  or  a  wrench  of  the  forearm,  probably  forced 
abduction  (Stimson),  or  a  fall  on  the  palm,  or  the  injury  may  occur  as 
an  incident  of  a  backward  dislocation  of  both  bones  of  the  forearm  or 
of  the  head  of  the  radius.  The  form  of  the  fracture  varies  with  the 
cause  :  fracture  of  a  small  portion  of  the  head  is  the  form  seen  in  dis- 
location and  in  fracture  by  direct  violence ;  the  more  extensive  frac- 
tures— splitting  of  the  head  and  complete  separation  from  the  shaft — 
are  seen  when  the  limb  has  been  violently  wrenched.  I  have  seen  five 
of  the  former — four  in  dislocation  and  one  by  direct  violence — and  five 
of  the  latter  verified  by  arthrotomy  and  four  probable  cases  observed 
clinically. 

In  the  cases  accompanying  dislocation  a  small  piece,  comprising 
about  one-third  of  the  periphery,  is  broken  ofT,  probably  the  portion 
that  is  anterior  when  the  head  is  forced  past  the  capitellum.  I  have 
found  it  lying,  after  reduction  of  the  dislocation,  beneath  the  external 
epicondyle  between  the  radius  and  the  olecranon,  and  the  portion  of 
the  head  of  the  radius  accessible  to  palpation  did  not  comprise  the  gap 
left  by  the  fracture.  In  one  case  the  fragment  had  been  displaced 
downward  along  the  neck  and  had  become  attached,  limiting  rotation ; 
I  cut  it  away  and  covered  the  raw  surfaces  with  silver  foil,  getting  a 
good  functional  result. 

In  a  case  of  fracture  by  direct  violence  (kick  by  a  horse)  Cheyne 
found  the  fragment  in  the  same  place  and  removed  it,  as  he  did  also  in 
another  supposed  to  be  by  direct  violence ;  in  another  Delorme  recog- 
nized abnormal  mobility  of  the  undisplaced  fragment  and  treated  it  by 
immobilization,  obtaining  complete  restoration  of  function.     In  mine 

1  Thomas:  Univ.  of  Penn.  Med.  Bull.,  vol.  18,  p.  184. 


FRACTURES  OF   THE  BONES  OF   THE  FOREARM. 


301 


the  patient  did  not  come  under  observation  until  after  suppuration  of 
the  joint  had  occurred;  resection  was  done. 


Fig.  203. 


A  B 

Fracture  of  head  and  neck  of  radius,    a,  first  case  :  b,  second  case  :  c,  third  case ;  the  portion 
corresponding  to  the  gap  was  crushed; 

My  five  certain  cases  of  fracture  by  violence  acting  througli  the 
forearm  resemble  one  another  closely.  In  each  the  cause  was  a  fall 
from  a  height,  the  arm  being  caught  under  the  body.  I  imagine  that 
the  immediate  cause  was  violent  abduction  of  the  forearm.  Fig.  203 
shows  the  lines  of  fracture.  In  the  first,  one  of  the  two  smaller  frag- 
ments was  displaced  outward  and  backward,  and  a  primary  excision  of 
the  head  and  neck  was  done,  with  a  good  functional  result.  It  was 
thought  that  the  coronoid  process  also  was  broken.  In  the  second 
there  was  no  recognizable  displacement  at  first,  and  I  was  not  entirely 
cei'tain  of  the  character  of  the  injury;  after  immobilization  for  four 
weeks  the  functional  result  seemed  so  likely  to  be  bad  that  I  opened 
the  joint  and  removed  the  head  and  neck,  finding  the  larger  fragment 
displaced  angularly  outward  and  backward  and  reunited  with  the  shaft. 
In  the  third  case  there  were  two  large  pieces  and  a  crush  of  the  inter- 
mediate portion,  also  fracture  of  the  coronoid  process  and  slight  dis- 
placement backward  of  the  ulna.  I  saw  the  patient  a  month  after  tlie 
accident  and  removed  the  head  of  the  radius.  In  the  fourth  case  the 
head  and  neck  were  split  and  broken  off,  and  in  the  fifth  the  fragment 
comprising  about  one-third  of  the  head,  antero-external,  was  detached 
and  displaced  downward  and  inward.  In  one  case  observed  clinically 
(details  in  first  edition)  reunion  followed,  with  a  good  functional  result, 
notwithstanding  a  notable  enlargement  of  the  upper  end  of  the  radius; 
in  the  other  rotation  of  the  forearm  was  lost.  I  have  also  had  a  case 
in  which  the  head  of  the  radius  was  broken  by  a  pistol-bullet  entering 
from  the  outer  side  and  above.  I  excised  the  head,  and  the  functional 
result  was  good.  The  details  of  these  cases  can  be  found  by  the 
references  given  in  earlier  editions. 

Two  of  INIiitter's  specimens  and  Helferich's  show  a  small  portion  of 
the  head  broken  oft'  and  reunited  with  displacement.  In  Pinner's  the 
small  fragment  was  eburnated  but  not  reunited,  and  in  Delorme's  the 
fragment  reunited  with  conservation  of  function. 

These  cases  show  that  union  is  possible,  even  probable,  after  fracture 
of  the  neck  or  of  the  head;  in  my  case  in  which  suppuration  followed 
the  patient  was  a  delicate  strumous  lad  in  whom  any  serious  joint  lesion 
would  have  been  likely  to  have  that  result. 


FRACTURES. 


Diagnosis.  The  diagnosis  after  fracture  of  a  small  portion  acoom- 
panying  a  dislocation  or  by  direct  violence  is  easy  if  the  fragment  is 
displaced  to  the  position  beside  the  olecranon  which  it  has  occupied  in 
most  of  the  reported  cases,  for  it  can  then  be  readily  palpated.     Its 


Fig.  204. 


Fracture  of  head  of  the  radius. 


removal  is  easy,  and  its  loss  appears  to  entail  no  disability.  The  loss 
of  rotation  observed  in  one  case  after  removal  was  probably  due  to 
adhesions  between  the  surface  of  fracture  and  the  capsule. 

In  the  cases  of  more  extensive  breaking  the  diagnosis  is  easy  if  there 
is  enough  displacement  of  the  head  to  be  recognized  by  palpation  and 
if  its  separation  from  the  shaft  is  shown  by  its  failure  to  share  in  rota- 
tory movements  of  the  forearm.  In  my  second  case  the  head  rotated 
with  the  shaft,  and  the  only  sign  pointing  to  its  fracture  was  an  occa- 
sional click  perceived  during  rotation  of  the  forearm  ;  there  was  also 
mai'ked  abnormal  lateral  mobility,  especially  adduction  of  the  forearm, 
and  sharp  pain  on  abduction.  If  it  cannot  be  felt,  the  diagnosis  must 
be  made  by  local  tenderness  on  pressure,  but  probably  the  a;-rays  are 
needed  for  a  positive  recognition. 

The  proper  treatment  of  this  condition  is  not  so  clear ;  one  of  my 
cases  regained  good  use  of  the  joint  without  operation  ;  another  did 
the  same  after  a  primary  excision ;  the  others  had  all  lost  more  or  less 
rotation  when  first  seen  some  weeks  after  the  accident,  and  some  of  them 
much  of  flexion  and  extension ;  the  removal  of  the  fragment  or  of  the 
entire  head  improved  the  condition.  The  results  recently  obtained  by 
massage  and  immobilization  in  cases  in  which  an  early  diagnosis  was 
made  are  encouraging,  but  I  doubt  if  small  completely  detached 
portions  of  the  head  should  be  left  in  ;  their  reunion  is  not  to  be 
expected  and  their  presence  is  always  a  danger.  Of  18  cases  of 
Thomas's  collection  in  which  the  result  is  known  there  was  good  union 
without  deformity  in  3,  with  deformity  in  5,  non-union  in  8,  1  bony 
and  1  fibrous  ankylosis,  and  2  with  greatly  impaired  function. 

Hitzrot's^  report  of  19  cases  clearly  shows  the  functional  advantage 

1  Hitzrot :  Annals  of  Surgery,  March,  1912. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


309 


of  removal  of  the  fragment  or  of  all  the  head — in  15  cases  treated  by  splints 
and  massage  at  least  half  of  the  rotation  was  lost  in  all  but  2;  in  4  cases 
with  displacement  treated  by  removal  of  the  fragment  or  of  all  the  head  ro- 
tation was  better  preserved,  and  was  practically  complete  in  those  in  wliich 
the  amount  of  l)one  removed  was  greatest.  This  is  readily  understood  when 
we  remember  that  the  cause  of  limitation  is  in  adhesions  formed  between 
the  fractured  surface  and  the  snugly  surrounding  orbicular  ligament. 


D.  Fractures  of  the  Neck  of  the  Radius. 

This  injury  appears  to  be  much  less  frequent  than  fracture  of  the 
head,  although  Mouchet^  saw  11  cases  in  the  course  of  two  or  three 


Fig.  205. 


Fracture  of  neck  of  the  radius. 

years,  all  in  children  under  thirteen  years  of  age.  Among  the  known 
specimens  are  one  of  Mutter's,  united  with  di.splacement,  one  each 
removed  by  Annandale,  Douglas,  Mouchet,  and  myself,  and  one  found 
by  Moullin  on  amputation.  Moullin's^  was  a  separation  of  the 
epiphysis.  In  several  other  cases  the  line  of  frac- 
ture has  been  shown  by  the  .r-rays  (Fig.  205). 
Mouchet's  is  shown  in  Fig.  206. 

In  November,  1902,1  saw  at  the  Hudson  Street 
Hospital  a  man  whose  right  elbow  had  been  dis- 
located (and  reduced)  two  days  previously.  The 
flexed  forearm  could  be  moved  slightly  backward 
and  forward  upon  the  arm,  there  was  a  gap  below 
the  capitellum,  and  the  head  of  the  radius  could 
be  plainly  felt  in  the  flexure  of  the  joint.  I  ex- 
posed the  joint  by  an  external  incision  and  removed 
the  head  of  the  radius,  which  had  been  ])rokcn  off* 
by  a  fracture  through  the  neck.  The  coronoid  was 
broken  at  its  base. 

'  Mouchet :  Revue  de  Chir.,  vol.  xxi.  p.  596. 

'MouUin:  Trans,  Path.  See.  London,  vol.  xxxix.  p.  242, 


of  neck  of  ra- 
(Mouchet.) 


310  FRACTURES. 

The  line  is  transverse  or  somewhat  oblique,  and  the  proximal  frag- 
ment usually  has  an  angular  displacement,  the  angle  opening  outward 
and  backward.  The  mode  of  production  has  varied  greatly — -a  fall  on 
the  hand,  a  blow  on  either  side  of  the  forearm,  a  wrench  of  the  forearm, 
a  crush  of  the  elbow  in  a  machine.  Dr.  Richard  Douglas,  of  Xash- 
ville,  reported  to  me  a  case  of  fracture  of  the  neck  by  a  blow  on  the 
inner  side  of  the  forearm,  verified  by  a  late  arthrotomy,  A  prominent 
feature  was  marked  flattening  of  the  inner  side  of  the  elbow,  with  ex- 
tensive ecchymosis,  which  I  attributed  to  avulsion  of  the  flexor  muscles 
in  forced  abduction  of  the  forearm.  Definite  diagnostic  features  are 
not  known  beyond  pain  at  the  site  of  fracture  and  especially  on 
attempting  supination  (Mouchet),  and  sometimes  recognizable  dis- 
placement. Here,  too,  the  .r-rays  will  probably  be  the  final  arbiter  in 
doubtful  cases. 

The  treatment,  when  there  is  no  marked  displacement,  is  immobili- 
zation with  the  elbow  at  a  right  angle  and  early  massage  and  gentle 
passive  rotation  of  the  forearm.  The  endangered  function  is  rotation. 
Hitzrot  (loc.  cit.)  reports  10  cases  thus  treated,  with  loss  of  about  one- 
fourth  of  rotation.  Mouchet's  9  fresh  cases,  in  children,  recovered  with 
good  function  after  treatment  by  massage  and  passive  motion.  If  the 
head  is  displaced  it  may  perhaps  be  pressed  back  into  place,  as  was 
done  by  Bolton  at  the  Xew  York  Hospital  in  1907  with  a  good  result, 
otherwise  its  removal  would  probably  give  a  better  functional  result 
than  its  conservation  would.  Late  removal  ma}'  be  done  to  improve 
function. 

2.    FRACTURES  OF  THE  SHAFT. 

A.  Fractures  of  the  Shafts  of  Both  Bones. 

These  occur  rarely  in  the  upper  third  and  with  about  equal  frequency 
in  the  middle  and  lower  thirds.  Skillern  {Annals  of  Surg.,  February, 
1915,  p.  209)  says  a  combination  of  fracture  of  the  radius  and  incom- 
plete fracture  of  the  ulna  is  frequent  in  childhood,  as  the  result  of  a 
fall  while  in  motion. 

Cause.  The  cause  may  be  direct  or  indirect  violence  or  muscular 
action,  a  fall  upon  the  hand,  or  the  bending  of  the  forearm  across  some 
object,  or  by  a  transverse  blow. 

Onlv  a  few  instances  of  fracture  by  muscular  action  have  been 
recorded,  and  even  in  those  there  was  a  contributing  external  force, 
such  as  shovelling  or  rising  upon  the  hand  in  bed. 

Partial  or  incomplete  fractures  —  "green- stick  fractures"  —  are, 
according  to  Malgaigne,  more  common  in  the  forearm  than  elsewhere, 
and  are  usually  due  to  a  fall  upon  the  hand. 

Displacements.  The  displacements  are  of  the  usual  kinds  :  overrid- 
ing in  oblique  fractures,  lateral  with  or  without  overriding  in  the 
transverse  fractures,  and  angular  displacement  of  one  or  both  bones  in 
both  forms.  Rotatory  displacement  of  the  radius  alone,  especially 
when  it  is  broken  above  the  insertion  of  the  pronator  teres,  was  first 
pointed  out  apparently  by  Lonsdale.  He  suggested  that  the  upper 
fragment  might  be  strongly  supiuated  by  the  biceps,  while  the  lower 


FRACTURES  OF  THE  BONES  OF   THE  FOREARM.  311 

fragment  was  kept  in  the  usual  semi-prone  position,  and  he  thought 
this  might  be  a  cause  of  the  inabihty  to  supinate  the  hand  completely 
sometimes  observed  after  fracture.  Flower  and  Hulke^  say  they  have 
found  proof  of  the  correctness  of  this  conjecture  in  the  examination 
of  numerous  specimens  of  united  fracture  of  the  radius,  "  in  a  great 
number  of  which  the  lower  fragment  was  much  less  supinated  than 
the  upper/'  and  Agnew  says  there  are  similar  specimens  in  the  collec- 
tions of  tlie  College  of  Physicians  and  the  University  of  Pennsylvania. 
Mr.  Callender^  examined  eighteen  specimens  of  united  fracture  of  the 
shaft  of  the  radius  in  the  London  museums,  and  found  in  fifteen  of  them 
rotatory  displacement  averaging  36  degrees,  the  extremes  being  6  de- 
grees and  64  degrees.  The  displacement  in  every  case  was  that  pointed 
out  by  Lonsdale,  supination  of  the  upper  fragment. 

Li  angular  displacement  one  bone  may  be  bent,  while  the  other 
remains  nearly  straight,  possibly  with  overriding,  or  the  fragments  of 
both  bones  may  be  inclined  in  the  same  direction,  forward,  backward, 
or  to  either  side,  or  there  may  be  lateral  inclination  in  opposite  direc- 
tions, each  bone  being  inclined  toward  the  other ;  and  if  the  fractures 
are  at  the  same  level  the  four  ends  may  thus  be  brought  into  contact, 
and  the  possibility  created  of  a  union  that  will  abolish  the  power  of 
rotation  of  the  limb.  Such  faulty  union  of  the  two  bones  is,  however, 
very  rare.  Overridino^  of  the  frag-ments  has  been  observed  to  a  dis- 
tance  of  more  than  three  inches  (eight  centimetres). 

Symptoms.  The  symptoms  are  the  usual  ones  of  fracture  :  pain, 
deformity,  abnormal  mobility,  cre])itus,  and  loss  of  power. 

The  course  is  usually  simple  and  the  prognosis  favorable,  but  both 
may  be  gravely  modified  by  laceration  or  bruising  of  the  soft  parts  or 
by  the  occurrence  of  acute  inflammatory  reaction  or  of  gangrene,  and 
in  addition  the  prognosis  may  be  made  unfavorable  by  an  irreducible 
displacement  or  comminution  or  loss  of  substance  of  one  of  the  bones. 
Displacement  affects  the  prognosis  when  it  increases  the  chances  that 
union  may  take  place  between  the  two  bones,  and  comminution  or  loss 
of  substance  by  favoring  the  occurrence  of  pseudarthrosis. 

In  simple  cases  without  marked  displacement  or  complication  com- 
plete union  may  be  expected  in  a  month,  but  in  no  other  limb  do 
inflammatory  complications  and  gangrene  occur  so  frequently,  even 
under  prudent  treatment.  The  gangrene  may  be  limited  to  points 
where  the  splints  have  made  pressure  or  to  portions  of  tlie  hand  and 
fingers,  but  it  is  very  likely  to  involve  the  entire  member  if  it  is  over- 
looked at  the  beginning  or  not  effectively  combated.  Diffuse  phleg- 
monous inflammation  of  the  forearm  may  follow  severe  bruising  of  the 
soft  parts  or  may  even  take  its  rise  in  the  fracture.  Its  im])ortance 
lies  in  the  danger  to  the  life  and  limb  which  follows  the  burrowing  of 
tlie  pus,  the  opening  which  it  necessitates,  and  the  matting  together 
of  the  tendons  and  their  sheaths. 

Ischsemic  contraction  of  the  nniscles  (p.  72)  is  of  especial  import- 
ance because  of  its  marked  interference  with  the  usefulness  of  the  hand. 

The  cause  of  gangrene  in  many  cases  and  of  ischsemic  contraction 

1  Hulke:   Holmes's  System  of  .Surgery,  Am.  ed.,  vol.  i,  p.  860. 

2  Callender:  St.  Bartholomew's  Hospital  Reports,  vol.  i,  1SG5,  p.  297. 


312  FRACTURES. 

has  been  pressure  exerted  by  splints  or  bandages,  and  the  necessity 
for  caution  and  watchfulness  to  avoid  this  accident  cannot  be  urged 
too  strongly.  The  practice  of  applying  a  roller  bandage  to  the  limb 
under  the  splints  is  extremely  dangerous,  and  so  also  is  the  use  of 
splints  of  soft  material,  pasteboard  and  the  like,  which  take  the  shape 
of  the  limb  and  are  fastened  to  it  with  a  roller  bandage.  There  is  the 
same  compression,  the  same  chance  of  strangulation  in  this  case  as 
when  the  roller  is  applied  directly  to  the  skin.  It  is  not  safe  to  depend 
upon  the  sensations  of  the  patient,  upon  pain,  to  give  warning  of 
threatening  strangulation  ;  cases,  in  both  old  and  young,  have  been 
reported  in  which  total  gangrene  of  the  distal  portion  of  the  limb  has 
occurred  without  attracting  the  attention  of  the  patient  or  his  attend- 
ants by  any  symptoms  except  the  final  change  in  the  color  of  the 
exposed  fingers. 

The  persistence  of  angular  displacement  of  both  bones,  or,  to  a 
less  degree,  of  the  radius  alone,  affects  the  prognosis  by  its  inter- 
ference  with   rotation.     In   rotation   only  the   radius  moves,  and   its 

Fig.  207. 


Fracture  of  forearm. 


movement  is  about  an  axis  running  from  its  upper  end  to  the  lower 
end  of  the  ulna,  so  that  in  full  pronation  the  radius  crosses  the  ulna 
obliquely,  and  in  supination  is  parallel  to  it  and  at  its  maximum  dis- 
tance from  it  at  the  centre.  If  now  the  bones  are  bent,  say  in  the 
middle  third,  the  radius  of  rotation  of  the  radius  at  the  apex  of  the 
angle  is  correspondingly  increased,  and  this  angle  must,  therefore, 
move  to  a  greater  distance  from  the  ulna  than  normal  in  sui)ination  ; 
such  a  movement  may  be  ])revented  by  the  interosseous  membrane,  and 
rotation  correspondingly  diminished.     This  is  a  frequent  cause  of  dim- 


FRACTURES  OF   THE  BONES  OF   THE  FOREARM. 


313 


inution  of  rotation  after  fracture.  Yet  the  marked  displacement  of  the 
radius  in  the  case  represented  in  Plate  XIII,  Fig.  1,  caused  the  loss 
of  only  half  of  the  rotation. 

The  possibility  of  union  between  the  bones  as  well  as  the  fragments, 
though  rare,  should  also  be  borne  in  mind.  Its  occurrence  is  more 
likely  when  the  natural  interval  between  them  is  destroyed  or  dimin- 
ished bv  displacement,  but  this  approximation  is  not  essential.  Excess- 
ive formation  of  callus,  in  consequence  of  laceration  of  the  intermediate 
tissues  and  irritation,  especially  of  the  interosseous  membrane,  is  suffi- 
cient in  itself  to  produce  this  result  so  injurious  to  the  usefulness  of 
the  limb.  The  occurrence  is  favored  also  by  correspondence  in  the 
position  of  the  fractures,  for  the  fragments  are  more  likely  to  fall  into 
abnormal  contact  with  each  other,  and  the  granulations  which  form  the 
callus  about  each  fracture  may  easily  unite  if  each  spreads  over  only 
half  the  intermediate  space  (Fig.  208).     It  has  occasionally  happened 


Fig.  208, 


Fig.  209. 


Fracture  of  the  forearm ,  angular  displacement, 
and  union  between  the  bones. 


Fracture  of  the  forearm,  with  formation 
of  a  lateral  joint. 


that  the  two  calluses  have  come  into  contact  and  formed  a  lateral  joint 
(Fig.  209),  instead  of  uniting.  Slight  inclination  of  the  hand  to  one 
side  or  the  other  is  a  not  infrequent  result  and  may  be  due  to  the  posi- 
tion of  the  sling  in  which  the  arm  is  supported ;  thus,  if  the  weight  of 
the  arm  is  borne  upon  the  sling  at  or  above  the  point  of  fracture  the 
unsupported  hand  drops  downward  and  the  lower  fragment  deviates 
toward  the  ulnar  side,  as  in  the  figures;  while  if  the  sling  passes  under 
the  hand  or  wrist  and  leaves  the  forearm  unsupjiorted  the  latter  sinks 
down  between  the  wrist  and  elbow  and  the  lower  fragment  deviates  in 
the  opposite  direction  toward  the  radial  side. 
22 


314 


FRACTURES. 


Delay  or  failure  of  union  of  either  or  both  bones  is  not  very  uncom- 
mon, especially  of  the  radius,  and  cases  are  reported  in  which  the  union 
of  one  of  the  bones  has  been  delayed  four  or  five  months,  and  has  then 
taken  place  without  operative  aid. 

Treatment.  Reduction  must  be  effected,  when  necessary,  by  exten- 
sion and  counter-extension,  aided  by  cautious  pressure  upon  the  bones 


Fig.  210. 

1^!^ 

^^^ 

j^^lH 

1 

^■j 

1  "-""^"^""^H 

^^^^>^^^|l 

i8k; 

■ 

^^^^1 

liif^^T-^^ 

^ 

^kt     ^^^^^ 

^ 

^^^^H 

H 

■ 

Fracture  of  the  forearm  ;  union  with  angular  displacement.    No  union  between  the  two  bones, 

near  the  seat  of  fracture.  The  importance  of  reduction  is  exception- 
allv  o:reat,  because  of  the  special  function  of  rotation  of  tlie  forearm 
which  mav  be  so  easily  destroyed  by  displacement  or  failure  of  union. 
I  have  oiice  or  twice  found  it  necessary  to  cut  down  upon  the  fracture 
because  I  could  not  otherwise  correct  "the  displacement,  the  fragments 
being  so  placed  after  oblique  fracture  that  the  surfaces  of  fracture  were 

Fig.  211. 


Fracture  of  forearm  ;  angular  di^placement. 


separated  from  each  other  by  the  entire  thickness  of  the  bone  and  the 
fragments  were  in  contact  only  by  surfaces  covered  with  periosteum. 
Overriding  is  to  be  overcome  by  traction  ;  the  forearm  and  fingers  are 
flexed,  counter-extension  is  made  by  an  assistant  who  grasps  the  arm 
close  above  the  elbow,  and  traction  by  the  surgeon  himself  or  another 


FRACTURES  OF   THE  BONES  OF   THE  FOREARM.  315 

assistant  grasping  the  hand.  If  there  is  angular  displacement  the 
traction  should  be  first  made  in  the  direction  of  the  lower  fragment, 
and  when  this  is  thought  to  he  sufficient,  and  while  it  is  still  main- 
tained, the  lower  segment  of  the  limb  is  brought  into  line  with  the 
upper  one,  the  lattter  being  steadied  by  the  hand  of  the  surgeon  or  press- 
ure being  made  upon  the  projecting  angle  Math  the  thumbs.  This 
pressure  may  be  safely  made  if  the  angle  is  directed  forward  or  back- 
ward, but  it  must  be  used  with  great  caution  when  the  angle  is  lateral, 
for  there  is  danger  that  it  may  force  the  bone  upon  which  it  is  made 
too  near  its  fellow,  and  that  when  the  manoeuvre  is  completed  the  posi- 
tion of  the  fragments  may  resemble  that  of  the  arms  of  an  X,  each  pair 
being  displaced  angularly  toward  the  other.  To  avoid  this  result  the 
hand  should  be  supinated  while  the  reduction  is  making,  because  in 
this  position  the  interval  between  the  bones  at  the  centre  of  the  limb  is 
greatest  and  most  accessible,  and  the  surgeon  should  seek  to  force  or 
keep  the  fragments  apart  by  pressing  his  thumbs  in  between  them  in 
front  and  his  fingers  behind. 

The  position  in  which  the  forearm  is  usually  kept  during  treatment 
is  that  which  is  midway  between  pronation  and  supination.  It  is  the 
one  which  the  limb  naturally  assumes  when  it  is  suspended  beside  the 
body  with  the  elbow  bent  at  a  right  angle  and  is  the  one  which  is 
borne  with  the  least  fatigue  and  discomfort.  But  while  this  position 
meets  the  indications  sufficiently  in  the  simple  and,  indeed,  in  most 
cases,  it  was  long  since  recognized  by  some  surgeons  that  the  bones  of 
the  forearm  are  normally  separated  most  widely  from  each  other  at  the 
centre  when  the  limb  is  supinated,  and  that  consequently  this  position 
is  the  one  in  which  the  arm  should  be  kept  whenever  there  appears  to 
be  danger  of  the  bones  uniting  with  each  other.  According  to  Mal- 
gaigne,  fractures  of  the  forearm  were  treated  in  the  supine  position  by 
the  contemporaries  of  Hippocrates,  but  the  practice  was  condemned  by 
that  writer  ;  it  was  reinvented  by  Pare,  and  abandoned  by  hini  when  he 
learned  that  Hippocrates  had  disapproved  of  it,  a  yielding  to  authority 
that  seems  to  have  been  unusual  with  that  vigorous-minded  surgeon, 
and  again  reinvented  by  Malgaigne,  who  afterward  learned  that 
Lonsdale  had  preceded  him  by  a  few  years.  Lonsdale  ^  recom- 
mended the  position  for  a  reason  mentioned  above,  the  difference 
between  the  degree  of  supination  of  the  upper  fragment  of  the  radius 
and  that  of  its  lower  fragment ;  Malgaigne  recommended  it  because 
of  the  greater  distance  between  the  centres  of  the  bones  when  they 
are  in  this  position. 

The  difficulty  which  Lonsdale  sought  to  avoid,  supination  of  the 
upper  fragment,  appears  not  to  have  much  importance  when  the  frac- 
ture of  the  radius  is  above  the  insertion  of  the  pronator  radii  teres  and 
to  be  rare  when  it  is  below  it ;  that  which  Malgaigne  had  in  mind — 
possible  union  of  the  two  bones — is  rare  even  when  the  two  bones  are 
broken  at  the  same  level.  The  principal  faults  to  be  avoided  are  angu- 
lar displacement  and  overriding,  and  so  far  as  these  are  concerned  the 
attitude  of  pronation  <n'  supination  seems  to  be  indifferent.  The  objec- 
tion to  the  attitude  of  su])ination  is  its  greater  constraint  and  incon- 
venience ;  if  the  attitude  is  desirable  the  discomfort  can  be  avoided  by 

1  Lonsdale:   London  Medical  (lazette,  1832,  vol.  ix.  p.  910. 


316 


FRACTVRES. 


confinement  to  bed  with  the  arm  abducted  and  the  elbow  flexed  at  a 
right  angle,  in  which  position  the  forearm  rests  easily  in  ftill  supination. 
A  common  method  of  treatment  is  to  fix  the  limb  between  two  light 
wooden  splints  broad  enough  to  overlap  it  slightly  when  applied  to  the 
palmar  and  dorsal  surfaces.  The  palmar  splint  should  extend  from  the 
fold  of  the  elbow  to  the  roots  of  the  fingers,  the  dorsal  one  should  be 
shorter  and  not  reach  beyond  the  wrist.  Each  splint  should  be  padded 
with  cotton,  and  patients  usually  find  it  agreeable  to  have  the  end 
corresponding  to  the  palm  of  the  hand  very  thickly  padded,  or  a  small 


Fig.  212. 


Moulded  plaster  splint  for  fracture  of  forearm. 

roll  of  bandage  fastened  obliquely  to  it  so  that  the  fingers  can  close 
easily  over  it. 

In  simple  cases  uncomplicated  by  threatening  displacement,  the 
splints  are  applied  to  the  semi-pronated  limb  and  fastened  by  two 
strips  of  adhesive  plaster  wrapped  about  them,  one  near  the  elbow,  the 
other  at  the  wrist,  the  hand  is  made  fast  to  the  palmar  splint  by  a  few 
ttirus  of  a  bandage,  and  the  limb  is  placed  in  a  sling  that  supports  both 
the  elbow  and  hand. 

The  limb  should  be  frequently  inspected  at  first  in  order  to  guard 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM.  317 

against  excessive  pressure  eitlier  by  bandages  too  tightly  applied  at  first, 
or  made  too  tight  by  the  swelling  of  the  parts,  and  the  splints  should  be 
removed  in  the  second  week  to  detect  and  remedy  any  new  displacement. 

A  roller  bandage  should  not  be  applied  to  the  limb  under  the  splints  ; 
it  exposes  to  displacement  by  pressing  the  bones  toward  each  other, 
and  to  gangrene  or  ischsemic  contraction  by  constriction.  The  com- 
plete plaster-of-Paris  dressing  is  objectionable  for  the  same  reasons 
during  the  first  few  days,  but  it  or  moulded  plaster  splints  including 
the  lower  portion  of  the  arm  may  be  used  after  the  first  week  if  care 
is  taken  not  to  make  lateral  pressure. 

Anterior  and  posterior  splints  immobilize  the  limb  sufficiently  to 
meet  every  indication  except  that  of  opposing  the  tonicity  of  the  mus- 
cles and  the  occurrence  of  overriding.  AVhen  the  lines  of  fracture  are 
transverse  or  toothed  the  bones  themselves  afford  sufficient  protection, 
and  in  any  case  flexion  of  the  elbow  relaxes  many  of  the  muscles  and 
diminishes  the  risk,  which,  moreover,  is  not  a  great  one. 

A  moulded  plaster-of-Paris  splint  dressing,  much  used  at  the  Hudson 
Street  Hospital,  especially  in  the  young,  is  shown  in  Fig.  212.  As  it 
extends  above  the  elbow  it  efficiently  opposes  shortening  if  traction  is 
maintained  while  the  plaster  hardens. 

In  compound  fractures  great  caution  should  be  used  in  removing 
fragments  or  excising  portions  of  bone,  lest  failure  of  union  should 
follow.  If  the  extent  and  position  of  the  wound  are  such  that  efficient 
splints  cannot  be  used  at  first,  the  patient  should  be  kept  in  bed  with 
the  arm  abducted  and  the  elbow  flexed,  and  traction,  elastic  or  bv 
weight,  made  by  means  of  adhesive  plaster  attached  to  the  hand  and 
wrist.  Counter-extension  can  be  made  from  the  lower  part  of  the  arm 
by  a  broad  bandage,  the  limb  being  meanwhile  supported  upon  cushions 
or  suspended,  and  preferably  steadied  by  a  splint  j^laced  outside  the 
dressings  of  the  wound. 

B.  Fracture  of  the  Shaft  of  the  Ulna. 

Fractures  of  the  shaft  of  the  ulna  alone  are  almost  invariably  the  re- 
sult of  direct  violence,  of  a  blow  received  upon  the  limb  while  it  is  raised 
to  protect  the  head,  or  of  a  fall  upon  the  ulnar  side  of  the  forearm. 

Displacement.  Displacement  may  be  entirely  absent,  and  when  pres- 
ent may  be  in  any  direction.  Its  extent  and  direction  seem  to  depend 
almost  entirely  upon  the  fracturing  force.  Most  recent  writers,  follow- 
ing the  example  of  Pouteau,^  have  alleged  that  the  broad  articulation 
of  the  ulna  with  the  humerus  prevented  lateral  displacement  of  tlie 
upper  fragment,  and  that  the  lower  fragment  was  thereff)re  tlie  only 
one  that  could  be  displaced  toward  the  radius.  Even  if  the  articula- 
tion w^as  absolutely  free  from  lateral  mobility,  the  inference  that  has 
been  thus  drawn  would  not  be  correct,  because  the  radius  can  be  moved 
toward  the  ulna  after  fracture  of  the  latter  and  thus  the  exact  equivalent 
of  the  displacement  of  tlie  ulna  toward  the  radius  produced.  The  only 
muscle  which  acts  directly  upon  the  lower  fragment  is  the  pronator 
quadratus,  tlie  tendency  of  which  is  to  draw  it  toward  the  radius. 

Symptoms.  The  symptoms  may  be  limited  to  pain  and  swelling  at 
the  scat  of  fracture,  and  if  their  significance  should  be  rendered  obscure 

'  I'outeau  :  CEnvres  posthunies,  178.3,  vol.  ii.  p.  258. 


318 


FRACTVRES. 


by  the  history  and  the  eifect  upon  the  soft  parts  of  the  direct  violence 
which  has  caused  the  fracture,  the  doubt  can  be  removed  by  noting  that 
pain  at  that  point  is  aroused  by  the  eifort  actively  to  extend  the  elbow 
against  opposition.  If  the  radius  remains  entire  and  is  not  dislo- 
cated at  either  end,  there  can  be  no  shortening  of  the  limb,  no  over- 
riding of  the  fragments,  and  displacement,  if  present,  must  be  recog- 
nized bv  following  the  outline  of  the  bone  with  the  finger.  Crepitus 
and  abnormal  mobility  may  be  obtained  by  grasping  the  limb  above 
and  below  the  fracture  and  making  pressure  alternately  upon  the  frag- 
ments with  the  fingers,  or  by  seizing  the  fragments  between  the  thumb 
and  fingers  and  moving  them  forward  and  backward  upon  each  other. 
An  important  and  not  infrequent  complication  is  dislocation  of  the 
head  of  the  radius  forward  ;  it  should  always  be  suspected  when  there 
is  marked  displacement  of  the  fragments  of  the  ulna  or  unusual  swell- 
ing at  the  elbow. 

Fig.  213. 


Fracture  of  ulna,  with  dislocation  of  head  of  radius  forward. 

The  prognosis  is  good  as  regards  repair  and  preservation  of  function. 

Reduction.  Reduction  can  be  made  only  by  appropriate  pressure  upon 
the  displaced  fragments,  traction  being  practically  without  value.  The 
displacement  which  it  is  most  important  to  overcome  is  the  lateral  one 
toward  the  radius,  and  that  should  be  met  in  the  same  way  as  after 
fracture  of  both  bones,  that  is,  by  pressing  the  thumb  and  fingers  in 
between  the  bones. 

As  the  radius  acts  as  a  splint  to  prevent  overriding  of  the  fragments 
the  surgeon's  chief  care  is  to  secure  immobility  and  prevent  lateral  or 
angular  displacement.  This  can  be  done  by  the  anterior  and  posterior 
splints  used  in  fracture  of  both  bones,  or  by  a  rectangular  splint  flist- 
ened  against  the  inner  side  of  the  arm  and  semi-pronated  forearm,  or 
by  a  moulded  plaster  splint.     In  some  cases  it  may  be  necessary  to 


FRACTURES  OF  THF  BONES  OF  THE  FOREARM.  319 

keep  the  forearm  supinated,  and  in  others  the  bruising  of  the  soft  parts 
may  be  so  severe  as  to  forbid  the  use  of  splints  at  first.  Tiie  arm 
shoukl  be  kept  in  a  sling  and  the  same  precautions  should  be  taken  to 
avoid  undue  pressure  by  the  sling  upon  the  ulna  as  when  both  Ijones 
have  been  broken.  A  pasteboard,  felt,  or  plaster  gutter  may  be  used 
to  avoid  this  danger. 

C.  Fracture  of  the  Shaft  of  the  Radius. 

As  far  as  can  be  judged  from  general  impressions  and  statistics  that 
are  somewhat  scanty,  isolated  fracture  of  the  shaft  of  the  radius  is  less 
frequent  than  that  of  the  ulna,  and  appears  also  to  be  generally  caused 
by  direct  violence,  sometimes  by  a  fall  upon  the  hand.  In  three  cases 
reported  by  Falkson  ^  fracture  in  the  middle  third  with  angular  dis- 
placement forward  was  caused  by  pressure  along  its  longitudinal  axis, 
the  palm  of  the  hand  in  dorsal  flexion  and  the  back  of  the  elbow 
having  been  caught  between  heavy  objects  which  were  approaching 
each  other.  Occasionally  it  has  been  broken  by  muscular  action — 
forcible  rotation. 

Displacements.  The  displacements  vary  somewhat  with  the  seat  of 
fracture,  the  causes  being  the  fracturing  force  and  the  action  of  the 
biceps  and  pronator  muscles.  The  more  common  displacement  appears 
to  be  an  angular  one,  the  apex  of  the  angle  directed  forward  and  inward. 
Plnte  XIII.  represents  an  extreme  form. 

The  possible  loss  of  supinatk)n  in  consequence  of  union  with  a  rota- 
tory displacement,  the  upper  fragment  being  completely  supinated  by 
the  biceps  while  the  lower  is  kept  partly  pronated  by  the  dressings, 
which  was  pointed  out  by  Lonsdale,  and  has  been  spoken  of  in  the  sec- 
tion on  fracture  of  both  bones,  is  also  to  be  borne  in  mind  after  frac- 
ture of  the  radius  alone,  especially  if  the  seat  of  fracture  is  above  the 
insertion  of  the  pronator  teres,  and  is  to  be  met,  if  at  all,  in  the  same 
manner,  that  is,  by  keeping  the  forearm  supinated,  but  it  does  not  appear 
to  interfere  noticeably  with  function. 

If  the  fracture  is  at  or  below  the  middle  of  the  bone  the  tendency  of 
the  biceps  and  pronator  teres  is  to  draw  the  lower  end  of  the  upper 
fragment  forward  and  inward,  and  that  of  the  pronator  quadratus  and 
supinator  longus  is  to  draw  the  upper  end  of  the  lower  fragment  toward 
the  ulna. 

Overriding  has  been  observed  only  when  dislocation  of  the  lower 
end  of  the  ulna  was  associated  with  the  fracture. 

Diagnosis.  The  diagnosis  is  made  by  recognition  of  the  displacement, 
if  it  exists,  of  crepitus  and  abnormal  mobility  obtained  by  grasping 
the  fragments  with  either  hand  and  moving  them  upon  each  other  or 
by  placing  a  thumb  upon  the  head  of  the  radius  and  rotating  the  wrist 
gently. 

Treatment.  The  indications  for  treatment  are  the  same  as  after  frac- 
ture of  both  bones,  except  so  far  as  the  uninjured  ulna  may  be  utilized 
as  a  splint  or  as  its  dislocation  may  require  more  or  less  prolonged 
traction.  If  displacement  exists  the  fragments  should  be  pressed 
back  into  place  as  before  described,  and  if  the  fracture  is  low  down 
and  the  lower  fragment  is  inclined  toward  the  ulna  it  will  perhaps  be 

1  Falkson  :  Ceritralblatt  fiir  Chirurgie,  1885,  p.  913. 


320  FRACTURES. 

found  easier  to  bring  it  back  into  line  by  drawing  the  hand  forcibly 
downward  and  toward  the  ulnar  side  than  by  pressing  the  fingers  in 
between  the  bones.  Traction  at  the  wrist  and  elbow  may  be  required 
to  overcome  dislocation  of  the  lower  fragment  upward  from  the  ulna. 

The  arm  should  be  secured  upon  well-padded  anterior  and  posterior 
wooden  or  moulded  splints  in  the  semi-pronated  position.  Dislocation 
at  the  lower  radio-ulnar  articulation  or  change  in  the  direction  of  the 
lower  articular  surface  of  the  radius  may  make  it  desirable  to  use  a 
moulded  splint  that  will  include  the  hand  and  perhaps  the  lower  part 
of  the  arm,  or  a  long  rectangular  one  for  the  purpose  of  extension  and 
counter-extension,  or  to  keep  the  hand  inclined  toward  the  ulnar  side. 

3.  FRACTURES  IN  THE  VICINITY  OF  THE  WRIST. 

A.  Fractures  of  the  Radius.     CoUes's  Fracture. 

Under  this  term  are  included  fractures  of  the  radius  near  the  wrist, 
which,  while  differing  from  each  other  in  many  respects,  have  in  com- 
mon a  characteristic  deformity,  and  often  a  certain  difficulty  in  making 
reduction. 

Next  after  the  ribs  the  lower  end  of  the  radius  is  the  part  of  the 
skeleton  most  frequently  broken.  AVhile  the  fracture  occurs  at  all 
ages,  it  is  most  frequent  in  the  elderly.  It  is  very  remarkable,  and 
worthy  of  mention  as  a  proof  of  the  difficulty  of  diagnosis  in  fractures 
near  a  joint,  as  well  as  of  the  force  of  authority  and  tradition,  that  the 
real  nature  of  this  common  injury  which  comes  so  frequently  under 
the  notice  of  all  surgeons  should  not  have  been  recognized,  and  that  it 
should  have  been  taken  almost  always  for  a  dislocation  of  the  wrist 
backward,  until  about  one  hundred  years  ago.  The  first  mention  of 
the  injury  as  a  fracture  is  generally  attributed  to  J.  L.  Petit,  but,  I 
think,  incorrectly,  for  I  find  no  reference  to  it  in  his  chapter  on  frac 
tures,  while  the  chapter  on  dislocation  of  the  wrist  contains  a  very  good 
clinical  description  of  it. 

Pouteau  ^  is  the  first  author  to  describe  it  as  a  fracture  and  to  point 
out  the  previous  universal  error  in  diagnosis.  He  describes  its  pathol- 
ogy, attributes  its  production  to  the  violent  contraction  of  the  prona- 
tors, and  gives  its  symptoms  and  treatm.ent,  adding  that  there  is,  per- 
haps, no  fracture  so  easy  to  recognize  at  a  glance.  The  fact  that  he 
includes  in  his  description  fractures  of  both  bones  does  not,  I  think, 
diminish  the  credit  due  him  for  his  recognition  of  the  error  of  his  pred- 
ecessors and  contemporaries.  His  view  of  the  subject  does  not  appear 
to  have  commended  itself  to  his  immediate  successors,  and,  during  the 
thirty  years  following  its  publication,  only  an  occasional  mention  is 
made  of  even  the  possibility  of  such  a  lesion,  and  the  common  injury 
was  still  deemed  a  dislocation. 

The  next  writer  upon  the  subject  failed  in  like  manner  to  impress 
his  opinion  upon  his  immediate  contemporaries,  and  although  justice 
was  ultimately  done  him,  and  the  fracture  is  now  known  widely  by  his 
name,  the  recognition  did  not  come  until  after  his  death.     Mr.  Colies 

•  Pouteau  :  CEuvres  posthumes,  1783,  vol.  ii.  p.  2b\. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM.  321 

publishefl  his  brief  but  accurate  account  of  the  fracture  in  1814/  but 
Dr.  R.  W.  Smith,  writing  in  1847,^  says:  "Subsequent  authors  have 
repeated  what  Mr.  Colles  had  said  upward  of  thirty  years  since,  but 
no  writer  (as  far  as  I  have  been  able  to  ascertain),  not  even  the  distin- 
guished author  of  the  Surgical  Dictionary,  has  alluded  to  his  account 
of  the  injury." 

Sir  Astley  Cooper,  in  the  second  edition  of  his  Dislocations  and  Frac- 
tures of  the  Joints,  published  in  1823,  describes  fracture  of  the  lower 
end  of  the  radius,  and  adds  that  he  had  seen  this  injury  frequently, 
but  did  not  understand  its  nature  until  taught  by  dissection  ;  but  he 
describes  at  the  same  time  dislocation  of  the  wrist,  and  evidently  did 
not  appreciate  the  full  character  and  frequency  of  the  fracture.  In  a 
subsequent  edition  he  describes  experiments  made  by  himself  upon  the 
cadaver  in  1833,  in  which  he  produced  the  fracture  by  hyperextension 
(extreme  dorsal  flexion)  of  the  hand.  The  same  failure  to  appreciate 
the  character  of  the  common  injury  which  was  coming  so  frequently 
under  the  care  of  every  surgeon  persisted,  notwithstanding  the  publi- 
cations of  Pouteau  and  Colles,  that  of  the  former  being  entirely  over- 
looked apparently,  and  that  of  the  latter  remembered  only  by  the 
Dublin  surgeons,  who  believed  in  the  fracture  and  gave  his  name  to  it. 
But  the  misapprehension  was  not  destined  to  last  long ;  the  great  change 
which  took  place  in  the  science  of  medicine  at  the  beginning  of  the 
present  century  under  the  inspiration  and  guidance  of  the  French 
physicians,  the  substitution  of  objective  knowledge  for  dogma,  of  clinical 
and  dead-house  observation  for  pure  speculation,  made  short  work  of 
this  error.  Dupuy  tren  was  the  first  to  call  attention  to  it  and  to  impress 
it  upon  the  profession  ;  a  post-mortem  examination  in  1820  showed 
him  the  real  character  of  the  injury,  and  his  hospital  service  gave 
him  the  clinical  opportunities  that  were  needed  for  study  and  demon- 
stration. A  short  period  of  doubt  followed,  and  then,  about  1830, 
the  fact  was  universally  accepted,  and  the  second  stage — that  of  dis- 
cussion of  details,  which  has  lasted  until  the  present  time — was 
entered  upon. 

Mr.  Colles,  who  had  never  had  an  opportunity  to  dissect  a  specimen 
of  the  fracture,  speaks  only  of  the  symptoms  and  treatment.  His  only 
statement  concerning  the  fracture  itself  is  an  incorrect  one  :  "  This 
fracture  takes  place  at  about  an  inch  and  a  half  above  the  carpal 
extremity  of  the  radius."  We  now  know  that,  while  the  line  of  frac- 
ture may  lie  at  the  point  he  mentioned,  it  is  usually  much  lower,  and  is 
often  associated  with  comminution  of  the  lower  fragment.  The  aver- 
age distance  is  differently  estimated,  possibly  because  some  have  meas- 
ured from  the  articular  edge  of  the  bone  and  others  from  the  styloid 
process ;  but  the  weight  of  testimony  places  it  at  from  one-third  to 
three-fourths  of  an  inch  above  the  articular  border.  In  the  young  it 
sometimes  follows  the  epiphyseal  line.  Its  direction  is  usually  trans- 
verse, but  it  may  be  oblique  laterally  or  antero-posteriorly,  and  the 
lower  fragment  is  often  comminuted.  The  lower  fragment  is  some- 
times displaced  l)odily  l)ackward  without  crushing,  as  in  Figs.  214  and 

1  Colles:  Edinburgh  Med.  and  Siir?.  Jonrnal,  Ajiril,  ]814,  vol.  x.  p.  J82. 

2  R.  W.  Smith:  "Fractures  iu  the  Vicinity  of  Joints,"  Am.  ed..  p.  1^9. 


322 


FRACTURES. 


215,  but  the  displacement  appears  more  often  to  be  almost  entirely 
angular,  the  lower  fragment  turning  upon  its  anterior  edge  as  upon  a 


Fig.  214. 


Fracture  of  the  lower  end  of  the 
radius.  Displacement  backward. 
(R.  W.  Smith.) 


Fig.  215. 


Fracture  of  the  lower  end 
of  the  radius.  Displacement 
of  lower  fragment  backward. 
(R.  W.  Smith.) 


Fig.  21G. 


Fracture  of  the  lower 
end  of  the  radius.  Angu- 
lar displacement  of  the 
lower  fragment  back- 
ward with  impaction. 
(R.  W.  Smith.) 


hinge,  crushing  or  penetration  with  impaction  taking  place  posteriorly 
and  outwardly,  and  the  articulating  surface  looking  downward  and 
backward    instead    of  downward   and   forward   as  it   does  normally ; 


Fig.  217. 


Fig.  218. 


^^^^^^7>^<^fiK:f^r'^ 


Various  forms  of  Colles's  fractures;  a;-ray  tracings. 


at  the  same  time  the  styloid  process  rises  to  a  higher  level.  An 
extreme  example  of  this  displacement,  with  union  is  showm  in 
Fig.  216.      Sometimes  the  styloid  process  of  the  ulna  is  broken  off, 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


323 


apparently  by  avulsion  through  the  lateral  ligament  or  possibly  the 
fibro-cartilage.       Some  authors  have  noted  this  complication  in  more 


Fig.  219. 


Fig.  220. 


Various  forms  of  Colles's  fracture;  x-ray  tracing. 


than  half  of  their  cases;  it  has  appeared  in  less  than  10  per  cent,  of 
my  skiagrams. 


324 


FRACTURES. 


Specimens  of  recent  fracture  are  not  very  common,  and  many  of 
those  we  possess  are  open  to  the  objection  that  the  fractures  have  been 
caused  by  violence  far  in  excess  of  that  which  causes  the  great  majority 
of  the  fractures  met  with  clinically,  the  patients  having  falling  from 
a  considerable  height,  and  having  received  other  injuries  that  caused 
death  within  a  short  time  thereafter.  Others  are  obtained  from  elderly 
patients  who  have  received  the  fracture  in  the  usual  manner,  that  is, 
by  a  fall  upon  the  ground  while  walking,  and  have  then  died  in  a  few 
days  of  an  intercurrent  aifection,  usually  pneumonia. 

The  Rdntgen  rays  have  recently  added  to  our  knowledge  of  the 
details,  showing  that  the  surface  of  fracture  is  rarely  flat  and  trans- 


FiG.  221. 


Various  forms  of  Colles's  fracture  ;  x-ray  tracing. 

verse,  that  comminution  or  splitting  of  the  lower  fragment  is  frequent 
even  in  early  adult  life,  and  that  the  displacement  backward  of  the 
fragment  is  not  commonly  so  marked  as  has  been  supposed  from  the 
appearance  of  the  limb.  They  confirm  the  opinion  that  the  radial  side 
of  the  bone  is  shortened  and  show  that  the  carpus  preserves  its  relations 
with  the  articular  surface  of  the  radius,  passing  slightly  upward  toward 
the  radial  side  of  the  ulna  and  thus  making  the  latter  prominent.  In 
marked  backward  displacement  the  ulna  accompanies  the  fragment. 

The  figures  and  Plates  XIIT.-XVIII.  show  the  different  levels  at 
which  the  fracture  occurs,  the  frequency  and  character  of  the  comminu- 
tion, the  difference  in  dorsal  displacement,  and  the  marked  dor.sal  pro- 


PLATE  XIII 


Fig.  1. — Fracture  of  Radius;   Marked.  Angular  Displacement. 


Fig.  2. — Recent  CoUes's   Fracture   in  a   Boy,  Twelve  Years  Old, 
showing   Epiphyses. 


PLATE  XIV 


Fig.  1. — Recent  Colles's  Fracture;   Male,  Twenty-two   Years. 
Same  as  Plate  XVIII,  Fig.  1. 


Fig.  2. — Old   Colles's   Fracture. 


PLATE  XV 


Kig.  1. — Recent  Colles's   Fracture;   Comminution;   Male,  Forty-five  Years. 


I« 

^ 

r^iiniti 

ti£4^,£;;>j& 

■-^ 

im^^l 

-v*^iJ?s!i<J^ 

"T^ 

-i' 

p 

M 

y 

1 

1 

■ 

^M 

H 

i 

1 

H 

•• 

i^ 

' 

1 

! 

} 

Fig.  2. — Recent  Colles's    Fracture;   Comminution;   Male,  Forty   Years. 

23 


PLATE  XVI 


Fig.  1. — Recent  Colles's   Fracture;   Male,  Twenty-six  Years.     Fall 
from  a  height  of  four  feet. 


Fig.  2. — Same  as   Fig.  1.      Side  view. 


PLATE  XVII 


Fig.  1. — Same  as  Plate   XVI.     After  reduction. 


Fig.  2. — Recent  CoIIes's   Fracture;   Male,  Fifty-six  Years. 
Fall  from,  a  height. 


PLATE  XVII I 


Fig.  1. — Recent  Colles's   Fraetvire;   Male,  Twenty-two  Years. 
Same  as   Plate  XIV,    Fig.  1. 


Fig.  2. — Conni-ninuted  Colles's   Fracture. 


PLATE  XIX 


Fig.  1. — Arrest  of  Growth  of  Radius  after  Colles's  Fracture  at  age  of 
Twelve  Years.     Present  age,  nineteen  years. 


Fig.  2. — Separation  of  Radial   Epiphysis;    Boy,  Fifteen  Years. 


PLATE  XX 


Fig.  1.— Normal  ^A^rist;   AdultMale. 


Fig.  2. — Nori-nal    Wrist;  Adult  Female.     Fracture  of  Third   Metacarpal. 


FRACTURES  OF  THE  BONES   OF  THE  FOREARM. 


325 


jection  of  the  first  row  of  the  carpus  hi  one.  Plate  XIX.,  Fig.  1, 
shows  arrest  of  growth  after  fracture  at  the  age  of  twelve  years,  the 
patient  being  nineteen  years  old  when  the  picture  was  taken.  Plate 
XX.  shows  the  normal  wrist  in  the  adult  male  and  female ;  the  notal)lv 
lower  position  of  the  articular  surface  of  the  radius  as  compared  with 


Fig. 222. 


Various  forms  of  Colles's  fracture;  a-ray  tracing. 

that  of  the  ulna  in  the  female  was  found  in  most  of  the  female  cases 
examined. 

In  specimens  obtained  after  repair  has  taken  place  without  reduction 
of  the  displacement  the  penetration  of  the  posterior  portion  appears  very 
marked  (Fig.  223),  often  more  so  than  it  really  is.  Tiie  appearance  is 
due  in  part  to  tlie  formation  of  callus  upon  the  posterior  face  of  the 
upper  fragment  under  the  periosteum  which  is  stripped  up,  the  "  peri- 


326 


FRACTURES. 


osteal  bridge,"  which  is  so  often  found  at  one  side  of  a  fracture,  and  in. 
part  to  condensation  of  the  spongy  tissues  during  repair. 

Among  the  lesions  that  may  be  associated  with  the  principal  fracture 
are  fracture  of  the  ulna  near  its  lower  end,  fracture  of  the  styloid 
process  of  the  ulna,  rupture  of  the  radio-ulnar  and  intra-articular  liga- 
ments, and  perforation  of  the  skin  by  the  ulna.  The  first  is  rare,  and 
all  the  others  are  the  consequence  of  the  momentary  prolongation  of 
the  action  or  of  variation  in  the  degree  of  the  fracturing  force. 


Fig.  223. 


Fig.  224. 


United  fracture  of  the  radius. 
Smith.) 


(R.  W. 


Recently  united  fracture  of  the  lowei  end 
of  the  radius.    (R.W.Smith.) 


Concerning  the  condition  of  the  intra-articular  fibro-cartilage  I  can 
find  but  little  that  is  positive,  since  the  only  sources  of  information  are 
the  autopsies  of  recent  fractures.  The  Rontgen  rays  give  no  direct 
information  on  this  point,  for  the  cartilage  is  transparent  to  them  ;  its 
avulsion  from  the  ulna  or  radius  seems  inevitable  when  the  lower  end 
of  the  radius  is  markedly  displaced. 

Although  much  stress  has  been  laid  by  some  upon  the  supposed 
rupture  of  the  internal  lateral  ligament,  fresh  specimens  and  experiment 
upon  the  cadaver  give  no  ground  for  the  belief  that  it  occurs  except  in 
ca.ses  with  marked  displacement.  The  fact  that  the  end  of  the  ulna  is 
prominent  and  that  the  finger  can  be  pressed  in  on  the  side  below  it 
much  more  deeply  than  in  a  normal  joint  can  be  explained  by  the 
ascent  of  the  carpus,  which  would  draw  the  ligament  to  a  more  trans- 
verse position. 

I  believe  that  in  the  severer  cases  the  tendon  of  the  extensor  carpi 
iilnaris  is  torn  out  of  its  sheath  and  displaced  outwardly  from  the  ulna, 
for  I  have  noted  in  such  cases  the  absence  of  the  resistance  which  the 
tendon  normally  offers  to  the  finger  close  below  the  joint. 

I  have  not  met  with  the  record  of  any  case  in  which  the  radius  pro- 
jected through  the  skin,  except  after  separation  of  the  epiphysis,  but  I 
have  seen  fractures  compound  on  the  radial  side. 


FRACTURES  OF   THE  BONES  OF   THE  FOREARM.  327 

Associated  fracture  of  the  scaphoid  has  been  observed  in  a  number 
of  clinical  and  experimental  cases,  and  that  of  the  semilunar  (Hunt) 
and  dislocation  of  the  semilunar  (Cameron)  have  been  reported.  (See 
Fractures  of  the  Carpus.)  Also  injury  of  the  median  nerve  by  stretch- 
ing across  the  edge  of  the  upper  fragment,  of  which  Blccher^  collected 
nine  cases.     The  symptoms  usually  appeared  after  an  interval. 

Cause.  The  cause  of  Colles's  fracture  is  usually  a  fall  upon  the  palm 
of  the  hand,  and  in  the  great  majority  of  cases  the  fall  is  only  to  the 
ground  while  walking.  This  is  true  of  almost  all  cases  in  which  the 
patients  are  somewhat  advanced  in  life ;  in  the  younger  ones  the  vio- 
lence is  usually  greater,  as  a  fall  from  a  height. 

The  mechanism  by  which  the  fracture  is  produced  has  been  the 
subject  of  much  discussion.  Three  theories  have  been  advanced  :  1. 
Fracture  by  splitting  or  crushing ;  the  cancellous  tissue  is  crushed  or 
comminuted  between  the  carpus  and  the  diaphysis.  2.  Fracture  as  in 
other  bones  by  decomposition  of  the  force  and  yielding  at  the  weakest 
point.  3.  Fracture  by  cross-strain  exerted  through  the  anterior  liga- 
ment in  exaggerated  and  forced  dorsal  flexion  (hyperextension)  of  the 
hand.  I  believe  that  almost  all  these  fractures  are  produced  accord- 
ing to  one  or  the  other  of  the  first  two  ways,  and  that  the  third  is  rarely 
seen. 

In  the  first  the  weight  of  the  body  is  received  upon  the  ball  of  the 
hand — the  carpus — directly  in  the  line  of  the  long  axis  of  the  radius, 
and  the  inner  end  of  the  scaphoid  or  the  semilunar  splits  the  end  of 
the  radius  like  a  wedge.  This  is  shown  by  many  specimens  and  appears 
to  be  especially  frequent  in  the  elderly. 

In  the  second  the  line  of  the  force  is  slightly  inclined  from  the  long 
axis  of  the  radius,  making  an  angle  open  anteriorly.  The  arm  is  out- 
stretched and  not  directly  in  the  line  of  the  fall.  The  force  is  decom- 
posed as  usual,  part  being  taken  up  by  the  resistance  of  the  shaft  in  the 
long  axis,  and  part  acting  transversely  to  break  the  bone.  The  back- 
ward displacement  and  tilting  of  the  lower  fragment  indicate  the  direc- 
tion of  this  component. 

According  to  the  third  theory  a  cross-strain  is  exerted  upon  the  end 
of  the  bone  through  the  anterior  ligament  of  the  wrist ;  the  force  is 
thought  to  be  received  upon  the  palm  of  the  extended  hand  at  a  point 
that  lies  posterior  to  the  posterior  border  of  the  end  of  the  radius,  the 
hand  is  bent  back,  the  ligament  is  put  upon  the  stretch,  and  the  bone 
is  broken  by  avulsion.  The  theory  seems  to  have  originated  in  experi- 
ments upon  the  cadaver.  The  earliest  recorded  experiments  in  this 
direction  were  those  already  alluded  to  which  were  made  by  Sir  Astley 
Cooper  in  1833,  but  not  published  until  several  years  afterward;  the 
earliest  publication  appears  to  have  been  by  Bouchet^  in  1834.  The 
experiment  may  produce  a  transverse  fracture  within  a  short  distance  of 
the  articular  surface  of  the  radius,  but  quite  as  often  it  causes  rupture 
of  the  anterior  ligament  and  even  dislocation  or  fracture  of  one  or 
more  of  the  carpal  bones.  There  is  no  doubt,  therefore,  that  the  frac- 
ture can  be  produced  in  this  way,  and  there  are  a  few  clinical  cases  in 

'  Bler-her:   Deutsche  Zeitsohrift  fiir  Chir.,  vol.  xciii,  p.  34. 

2  Bouchet:  Th^se  sur  les  Luxations  du  Poignet.     Quoted  by  Malgaigae. 


328 


FRACTURES. 


which  this  was  apparently  the  mode  of  production.  But,  with  the 
exception  of  these  few  cases,  in  which  the  mode  of  action  of  the  vio- 
lence was  distinctly  exceptional,  there  is  nothing  but  the  experiments 
to  support  the  theory.  In  other  clinical  cases  the  same  movement  has 
produced  dislocation  of  the  semilunar  or  fracture  of  the  scaphoid  or 
semilunar.  (See  also  Poulsen,  Arch.  Uin.  Chir.,  vol.  80,  p.  902,  and 
Cartruccio,  Beitrdge  zur  klin.  Chir.,  vol.  53,  p.  66.) 

The  violence  in  a  fall  is  not  usually  received  at  a  point  on  the  palm 
of  the  hand  posterior  to  the  line  of  the  radius  so  as  to  bend  the  hand 
backward ;  it  is  received  at  the  base  of  the  thumb,  at  a  point  corre- 
sponding to  the  trapezium,  or  along  the  carpus,  and  is  transmitted 
directly  to  the  radius  as  above  described.  Moreover,  the  theory  fails 
to  explain  the  comminution  so  frequently  seen  and  fractures  above  the 
conjugal  cartilage  in  the  young. 

Symptoms.  The  symptoms  are  marked  and  characteristic,  but  crep- 
itus and  abnormal  mobility,  so  common  in  other  fractures,  are  not 
always  easily  recognizable  in  this.  The  most  striking  features  of  the 
deformity  are  the  prominence  of  the  dorsum  over  the  lower  fragment 
and  that  of  the  end  of  the  ulna.  The  former  so  changes  the  outline 
of  the  forearm  and  wrist  that  when  viewed  from  the  radial  side  its 
appearance  is  like  that  represented  in  Fig.  225,  and  was  aptly  com- 
pared by  Velpeau  to  the  outline  of  a  silver  fork,  a  comparison  which 
has  survived  in  the  name  "silver-fork  fracture,"  by  which  it  is  some- 
times known.     The  cause  of  this  change  in  the  outline,  so  far  as  it  is 

Fig.  225. 


Deformity  in  CoUes's  fract\ire. 

due  to  the  position  of  the  fragments,  is  shown  in  some  of  the  radio- 
graphs ;  swelling  of  the  soft  parts  and  even  projection  of  the  first  row 
of  the  carpus  accounts  for  some  of  it ;  that  of  the  palmar  aspect  is 
due  mainly  to  swelling  of  the  soft  parts. 

The  radiographs  show  that  the  characteristic  deformity  is  present 
even  when  the  displacement  of  the  fragment  is  slight,  and  that  in 
general  this  displacement  is  much  less  than  has  heretofore  been  sup- 
posed. 

The  prominence  of  the  end  of  the  ulna  appears  to  be  due  to  the 


FRACTURES  OF   THE  BONES  OF   THE  FOREARM.  329 

displacement  of  the  carpus  and  the  fragment  of  the  rachus  upward 
and  somewhat  to  the  radial  side,  aided  sometimes  by  avulsion  of  the 
styloid  process  of  the  ulna,  or,  possibly,  the  equivalent  rupture  of  the 
internal  lateral  ligament.  That  ascent  of  the  end  of  the  radius  is 
sufficient  to  produce  this  prominence  is  shown  by  its  gradual  appear- 
ance in  cases  of  arrest  of  growth  at  the  lower  end  of  that  bone.  (See 
Plate  XIX.) 

If  the  surgeon  marks  the  positions  of  the  styloid  processes  bv  press- 
ing the  end  of  a  finger  into  the  side  of  the  joint  below  and  against  the 
end  of  each,  he  will  see  that  that  of  the  radius  has  risen,  so  that 
instead  of  being  about  a  quarter  of  an  inch  lower  (nearer  the  hand) 
than  that  of  the  ulna,  as  it  usually  is,  it  has  risen  to  the  same  level,  or 
even  above  it. 

The  swelling  upon  the  anterior  surface  of  the  forearm  is  quite 
marked,  and  is  sharply  rounded  off  toward  the  wrist  with  deepening 
of  the  transverse  creases. 

Crepitus  and  abnormal  mobility  can  sometimes  be  obtained  by 
grasping  the  lower  fragment  between  the  thumb  and  fingers  and  mov- 
ing it  backward  and  forward  while  the  forearm  is  steadied  by  the 
other  hand. 

Pressure  along  the  line  of  fracture  on  the  dorsum  of  the  radius  or 
of  the  hand  upward  against  the  forearm  is  painful. 

Diagnosis.  The  diagnosis  is  made  by  recognition  of  the  above  signs 
and  symptoms.  In  difficult  cases,  fat  people  and  children  without 
displacement,  it  may  be  made  upon  the  existence  of  a  well-defined 
transverse  line  of  tenderness  on  pressure  on  the  dorsum  of  the  radius, 
pain  at  the  same  point  when  the  hand  is  pressed  upward  against  the 
radius,  deepening  of  the  transverse  folds  on  the  palmar  aspect  of  the 
wrist,  loss  of  power  in  the  limb,  and  history  of  the  case.  Care  should 
be  taken  not  to  confound  it  with  or  overlook  coincident  fracture  of 
the  scaphoid. 

A  sprain  or  contusion  may  be  mistaken  for  a  fracture  if  the  limb 
has  been  broken  previously  and  has  united  with  deformity,  for  it  will 
present  some  of  the  physical  and  functional  signs.  The  question 
therefore  should  always  be  asked  whether  the  wrist  has  suffered  a  pre- 
vious injury. 

Course  and  Prognosis.  Firm  union  between  the  fragments  may  be 
expected  within  a  month.  The  prognosis  with  reference  to  deformity 
depends,  of  course,  upon  the  completeness  of  the  reduction  and  reten- 
tion. As  a  rule,  permanent  deformity  after  fracture  in  youth  is  slight 
or  entirely  absent ;  but  in  adults  the  case  is  different,  either  because 
the  original  displacement  is  greater,  or  because  crushing  and  comminu- 
tion make  complete  reduction  and  retention  practi(;ally  imjHjssiblc. 

Tiie  prognosis  with  reference  to  fiincti(»n  is  somewhat  better,  since 
the  persistence  of  even  marked  displacement  does  not  necessarily 
entail  disability.  The  range  of  motion  at  the  wrist  may  be  somewhat 
restricted,  and  yet  may  be  wide  enough  to  answer  all  purj^oses,  and  a 
change  in  the  direction  of  the  articuhir  surface  is  still  (•omi)atil)le  with 
free  and  painless  motion.  Restriction  of  supination  is  common  for 
some  time  after  recovery,  presumably  because  of  infiltration  of  the 
24 


330  FRACTURES. 

pronator  quadratus.  Rigidity  of  the  wrist  and  fingers  usually  persists 
for  some  weeks,  or  even  months,  and  in  exceptional  cases,  in  the  old 
and  rheumatic  and  in  those  where  there  has  been  much  inflammation 
of  the  sheaths  of  the  tendons  and  of  the  wrist- joint,  it  may  persist  for 
years.  Our  recently  gained  knowledge  of  fracture  of  the  scaphoid 
suggests  that  the  disability  in  some  of  these  reported  cases  has  been  due 
to  the  co-existence  of  that  injury.  I  have  seen  two  cases  in  which  the 
hand  was  practically  useless  a  year  or  two  after  the  receipt  of  the  injury. 
There  was  much  deformity  in  one  of  them.  This  rigidity  of  the  fingers 
is  due  in  part  to  their  prolonged  immobilization  and  in  part  possibly  to 
inflammation  within  the  sheaths  of  their  tendons  in  the  forearm. 
Heinecke^  reports  two  cases  in  which  the  tendon  of  the  extensor  secundi 
internodii  broke  eight  and  four  weeks  respectively  after  the  injury, 
during  use  of  the  hand.  He  attributes  it  to  persistent  pressure  upon 
the  tendon  by  the  edge  of  the  annular  ligament. 

The  possible  arrest  of  the  growth  of  the  bone  after  separation  of  the 
epiphysis  in  the  young  deserves  mention,  although  it  is  an  exceptional 
consequence  of  the  injury.   I  have  seen  two  such  cases.   (Plate  XIX.) 

Treatment.  Complete  reduction  of  the  displacement  is,  of  course, 
essential  to  prevent  permanent  deformity.  The  ease  with  which  it  can 
be  accomplished  varies  greatly  in  different  cases.  Traction  upon  the 
hand  with  direct  pressure  upon  the  fragment  is  sometimes  sufficient  to 
correct  the  dorsal  displacement;  in  other  cases  forcible  pressure  must 
be  made,  the  forearm  is  grasped  with  the  fingers  upon  the  palmar 
prominence  and  the  thumbs  upon  the  dorsal  one,  and  the  pieces  pressed 
into  line.  Occasionally  an  anaesthetic  must  be  given  and  the  fragment 
mobilized  by  moving  it  forcibly  backward  and  forward  and  then  press- 
ing it  into  place. 

In  order  to  meet  the  two  indications — the  prevention  of  posterior 
displacement  of  the  lower  fragment  and  of  projection  of  the  end  of  the 
ulna — a  great  variety  of  splints  have  been  devised,  most  of  them  upon 
the  theory  that  the  position  of  the  fragment  can  be  controlled  by  the 
attitude  given  to  the  hand.  Thus,  palmar  flexion  of  the  wrist  has 
been  employed  to  prevent  backward  displacement  of  the  fragment  of 
the  radius,  and  ulnar  flexion  to  prevent  the  prominence  of  the  ulna. 
The  theory  is  wrong  and  the  results  have  disappointed.  If  the  dorsal 
displacement  has  been  corrected  it  has  little  tendency  to  recur,  and  the 
attitude  of  the  hand  is  without  influence  upon  it ;  the  projection  of  the 
end  of  the  ulna  cannot  be  prevented  by  ulnar  flexion  of  the  Avrist,  for 
this  movement  does  not  bring  back  the  carpus  and  the  radial  fragment 
to  their  normal  positions. 

The  facts  to  be  borne  in  mind  are  :  1.  That  dorsal  prominence  of  the 
fragment  is  to  be  prevented  by  correction  of  the  displacement  before 
the  application  of  a  dressing,  and  its  recurrence  prevented  by  direct 
action  upon  the  fragment,  not  by  indirect  action  through  the  hand. 
2.  That  some  permanent  shortening  of  the  radius,  especially  on  its 
outer  side,  if  its  cancellous  tissue  has  been  crushed,  as  is  the  rule  in 
the  old  and  frequent  in  others,  is  inevitable.     3.  That  the  prominence 

1  Deutsche  Ztschft.  f.  Nervenheilkund,  vols.  97  and  98. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


331 


of  the  ulna  can  be  prevented  only  by  bringing  the  fragment  of  the 
radius  (and  thus  the  carpus)  fully  back  to  its  normal  position — a  prac- 
tical impossibility  in  many  cases.  Direct  lateral  pressure  upon  the 
sides  of  the  wrist  may  diminish  the  prominence  in  some  cases.  4. 
That  the  fingers  must  be  left  free  in  order  to  avoid  the  stiffening  caused 
by  their  confinement. 

A  suitable  dressing,  therefore,  is  one  which  immobilizes  the  fragment 
and  the  carpus  in  the  ])osition  given  to  them  and  leaves  the  fingers  free 
to  be  flexed  and  extended  at  will ;  and  as  the  tendency  to  recurrence  of 
the  dorsal  displacement  is  slight  special  precautions  against  it  are  rarely 
needed. 

Such  a  dressing  may  be  made  of  plaster-of-Paris  or  wooden  splints. 
The  most  convenient  attitude  is  that  of  partial  pronation  with  the  wrist 
in  slight  dorsal  flexion  and  the  fingers  flexed.  There  should  be  two 
splints,  palmar  and  dorsal,  the  former  extending  from  a  little  below 
the  elbow  to  the  metacarpo-phalangeal  joints,  the  latter  from  the  same 
height  to  the  carpo-metacarpal  joints. 

Wooden  splints  (Fig.  226)  should  be  three  inches  broad  and  padded, 
the  padding  being  a  little  thicker  on  the  palmar  splint  at  the  point  cor- 
res]>onding  to  the  lower  end  of  the  upper  fragment,  and  on  the  dorsal 
splint  at  the  point  corresponding  to  the  lower  fragment.  A  roller- 
bandage  placed  obliquely  at  the  lower  end  of  the  palmar  splint  makes 
a  convenient  rest  for  the  hand,  maintains  dorsal  flexion  of  the  wrist, 
and  permits  the  fingers  to  be  clasped  over  it.  The  splints  are  secured 
in  place  by  two  adhesive  bands,  one  at  each  end,  and  by  a  roller- 
bandage. 

Plaster-of-Paris  splints  (Fig.  227)  should  be  wide  enough  to  cover 
in  the  wrist,  and  the  lower  end  of  the  palmar  one  may  be  conveniently 
made  into  a  roll  to  fill  the  palm  of  the  hand.  The  dorsal  one  may 
extend  upon  the  back  of  the  hand.  Tliey  should  be  secured  in  place 
by  a  roller-bandage,  and  while  the  plaster  is  setting  it  may  be  held 
snugly  against  the  sides  of  the  wrist  so  as  to  keep  the  ends  of  the 
radius  and  ulna  close  together.    They  are  especially  advantageous  in  per- 


FiG.  226. 


Wooden  splints  for  Colles's  fracture. 

mitting  daily  massage  of  the  parts  :  the  dorsal  splint  is  removed  and 
massage  made  on  the  uncovered  portion  from  the  beginning,  and  the 
palmar  one  can  be  removed  for  the  same  purpose  (the  dorsal  one  being 
kept  in  place)  after  tlie  first  week.  The  patient  must  be  instructed  to 
keep  the  fingers  flexed  when  at  rest,  and  to  move  them  frequently. 
It  is  well  also  to  keep  the  thumb  abducted. 


332 


FRACTURES. 


The  question  sometimes  arises  whether  the  deformity,  persisting  for 
some  time  after  the  injury  and  the  result  of  an  error  in  diagnosis  or  of 
failure  of  treatment,  can  be  corrected.     Among  Dupuytren's  earliest 


Fig.  227. 


Plaster-of-Paris  splints  for  Colles's  fracture. 

cases  were  three  of  this  kind,  and  he  succeeded  in  overcoming  the 
deformity  by  steady  forcible  traction  and  pressure  upon  the  fragments 
on  the  twentieth,  twenty-ninth,  and  thirtieth  days  after  the  receipt  of 
the  injury,  the  patients  being  respectively  sixty-nine,  ten,  and  thirteen 
years  old.  A  few  cases  have  been  treated  by  refracture  or  by  incision 
and  osteotomy.  I  doubt  if  anything  more  than  an  improvement  in 
appearance  can  be  gained  thereby ;  the  causes  of  loss  of  function  can- 
not be  thus  removed. 


B.  Fractures  at  the  Wrist  Other  than  CoUes's. 

Dr.  Rhea  Barton,^  of  Philadel])hia,  described  clinically  a  fracture 
which  he  said  was  very  common,  and  which  he  supposed  to  be  the 
detachment  of  the  posterior  border  of  the  articular  surface  of  the 
radius.  It  does  not  appear  from  his  paper  that  he  had  ever  had  an 
opportunity  to  verify  the  diagnosis  by  examination.  A  few  specimens 
of  such  a  fracture,  most  of  them,  I  believe,  found  in  the  dissecting- 
room  and  without  history,  are  in  existence,  and  the  injury  is  known  in 
America  as  Barton's  fracture.  Dr.  Agnew  ^  figures  a  specimen  in  which 
the  fragment  is  much  larger.  It  is  perhaps  hardly  worth  while  to  try 
now  to  change  this  name,  but  there  are  three  good  reasons  why  the 
injury  should  not  be  known  as  Barton's  fracture  :  1st,  as  a  reference  to 
the  original  article  shows,  the  injury  which  Barton  described  clinically 
was  not  what  he  supposed  it  to  be  anatomically,  but  was  the  ordinary 
Colles's  fracture ;-  2d,  the  lesion  as  he  supposed  it  to  be,  had  been 
observed  some  years  before  his  paper  was  published,  and  the  specimen 
was  presented  by  Lenoir^  to  one  of  the  Paris  societies;  and,  3d,  it 
deserves  to  be  classed  not  as  a  variety  of  fracture,  but  as  a  complica- 
tion of  dislocation  of  the  carpus  backward.  In  Lenoir's  case,  which  is 
described  as  a  dislocation  by  Yoillemier  and  Malgaigne,  a  narrow  frag- 
ment of  the  posterior  articular  border  had  been  broken  off,  remained 
attached  to  the  capsule,  and  was  displaced  backward  with  the  bones  of 
the  wrist.     I  have  seen  two  such  cases. 

I-  Barton :  Medical  Examiner,  1838,  p.  365. 

2  Agnew:  Loc.  cit.,  vol.  i.  p.  905. 

2  Lenoir:  This  fact  is  mentioned  by  Yoillemier.  in  the  Archives  Generales  de  Mede- 
cine,  1839,  vol.  vi.  p.  402.  and  by  Malgaigne.  The  Society  referred  to  is  probably  the  Soci- 
ete  Anatomique,  but  I  have  failed  to  find  mention  of  the  specimen  in  its  Bulletins. 


FRACTURES   OF  THE  BONES  OF  TBE  FOREARM.  333 

An  analogous  case,  dislocation  of  the  carpus  forward  with  detachment 
of  the  auferior  border  of  the  articular  end  of  the  radius  and  fi-acture 
of  the  styloid  process,  was  reported,  with  the  specimen,  to  the  Societe 
Anatomique,  by  Letenneur.^  The  patient  was  brought  to  the  Hotel- 
Dieu  May  7,  1838,  having  received  this  injury  and  also  a  fracture  of 
the  scaphoid  bone  of  the  other  wrist,  by  falling  into  a  ditch  while 
intoxicated.  Mr.  Callender'  refers  to  a  somewhat  similar  specimen, 
but  one  in  which  the  fragment  is  much  larger,  in  the  following  words: 
"  The  line  of  fracture  is  four-tenths  of  an  inch  from  the  end  of  the 
radius  on  the  palmar  surface,  but  on  the  dorsal  passed  into — along  the 
edge  of — the  articular  facets."  A  case  demonstrated  by  the  .r-ray  is 
reported  by  Shoemaker.^ 

Other  infrequent  fractures  of  the  region  may  be  conveniently  men- 
tioned here  : 

A  condition  in  which,  the  line  of  fracture  l)eing  the  same  as  in  Col- 
leges fracture,  the  lower  fragment  is  displaced  toward  the  palmar  side, 
and  the  crushing  is  also  on  that  side.  Mr.  Callcnder*  reports  such 
a  case  caused  by  forced  Hexion  of  the  hand  in  a  fall  upon  it:  there 
was  a  well-marked  prominence  on  the  dorsum  of  the  forearm  about 
three-fourths  of  an  inch  above  the  wrist-joint,  and  opposite  it  on 
the  palmar  surface  was  a  considerable  depression.  The  lower  frag- 
ment of  the  radius  was  inclined  at  an  oblique  angle  to  the  palmar  sur- 
face, and  projected  at  the  wrist.  No  crepitus.  Reduction  could  not 
be  effected.  Ten  months  later  the  deformity  persisted,  with  good  rota- 
tion, exaggerated  flexion,  and  inability  to  extend  the  hand  beyond  a 
straight  line  with  the  forearm. 

Callender  mentions  also  two  specimens,  one  in  the  museum  of  West- 
minster Hospital,  the  other  at  St.  Bartholomew's,  which  show  the  cor- 
responding displacement  with  union.  In  one  the  styloid  process  of 
the  ulna  was  broken  and  the  lower  fragment  of  the  radius  displaced 
forward  and  outward,  especially  in  the  latter  direction,  with  penetra- 
tion on  the  palmar  surface,  to  the  depth  of  more  than  three-tenths  of 
an  inch.  In  the  other  the  line  of  fracture  is  rather  more  than  an  inch 
above  the  end  of  the  bone;  there  is  a  prominent  angle  on  the  dorsal 
aspect  in  the  line  of  the  fracture  and  an  elevation  of  new  bone  on  the. 
corresponding  part  of  the  palmar  surface  ;  the  triangular  fibro-cartilage 
was  almost  completely  separated  from  the  radius. 

R.  W.  Smith  5  describes  and  figures  a  similar  case,  in  which  also  the 
fracture  was  caused  by  a  fall  upon  the  back  of  the  hand,  and  I  know 
of  one  seen  by  Dr.  Keyes. 

The  diagnosis  is  made  by  attention  to  the  position  of  the  styloid 
process  with  reference  to  the  carpus  and  the  ulna  and  by  recognition 
of  the  line  of  limited  tenderness  if  mobility  and  crepitus  cannot  be 
obtained.  The  treatment  should  be  the  same  as  in  Colles's  fracture, 
except  that  the  position  of  the  pads  should  be  changed  to  meet  the 
different  displacements.     The  subject  has  been  treated  in  detail  by  Dr. 

1  Letenncur:   Bulletins,  vol.  xiv.  p.  162. 

2  Callender:  Loc.  cit.,  )).  291. 

^Slioemaker:  Annals  of  Surgerj',  August,  1904,  p.  284. 
*  Callender  :  Loc.  cit.,  p.  289. 
'  li.  W.  Smith :  Loc.  cit.,  p.  162. 


334 


FRACTURES. 


Fig.  228. 


J,  B.  Roberts  in  Am.  Jour.  Med.  Sc,  January,  1897;  see  also  Idem., 
September,  1904,  p.  423,  for  two  cases  seen  by  him  and  one  by  Stewart. 
An  oblique  fracture  running  downward  and  inward  and  detaching 
the  styloid  process  of  the  radius  with  more  or  less  of  the  articular  por- 
tion; the  larger  the  fragment  the  more 
closely  will  the  symptoms  resemble 
those  of  Colles's  fracture.  The  injury 
is  rare.  In  the  few  cases  I  have  seen 
and  in  those  reported  the  fragment  has 
been  quite  large.  Usually  the  displace- 
ment is  slight,  but  in  one  case  the  frag- 
ment was  drawn  upward  one  and  a  half 
inches.  Immobilization  of  the  wrist 
appears  to  be  all  that  is  needed.  Wil- 
hoit^  reports  a  case  in  which  the  frac- 
ture ran  downward  and  outward,  de- 
taching the  inner  portion  of  the  lower 
end  of  the  bone. 

Longitudinal  fracture  or  fissure  of  the 
end  of  the  bone.  Dr.  Bigelow-  re- 
ported one  case  and  referred  to  a  second. 
There  was  a  star-shaped  crack  on  the 
articular  surface  without  displacement 
and  slight  corresponding  cracks  in  the 
shaft  for  more  than  an  inch  above.  At 
first  there  was  only  lameness  at  the 
wrist,  but  after  several  days  there  were 
swelling  and  tenderness,  the  persistence  of  which  led  Dr.  Bigelow  to 
make  the  diagnosis.  He  had  had  a  similar  case  two  years  before,  with 
the  same  symptoms,  but  less  extensive  injury  to  the  bone.  I  have  seen 
one,  shown  by  skiagram.  It  is  clearly  an  incomplete  Colles's;  if  the 
violence  had  been  greater  the  fracture  would  have  been  the  usual  one. 
Fracture  of  the  styloid  process  of  the  ulna  is  sometimes  observed  sepa- 
rately as  the  result  of  direct  violence.  In  addition  to  the  usual  symp- 
toms of  pain  and  swelling,  mobility  of  the  process  could  probably  be 
recognized  by  direct  manipulation  or  by  abduction  of  the  hand.  Dr. 
Agnew  says  some  deformity  is  likely  to  remain,  and  that  in  the  only 
case  he  had  seen  the  union  was  fibrous.  He  advises  treatment  upon  an 
anterior  splint  with  the  hand  inclined  toward  the  ulnar  side  and  in 
dorsal  flexion,  so  as  to  relax  the  extensor  carpi  ulnaris. 

Fracture  of  both  bones  near  the  wTist  is  occasionally  seen.  The  diag- 
nosis is  made  by  recognition  of  the  abnormal  mobility  of  the  fragments. 
Treatment  as  in  Colles's  fracture. 

1  Wilhoit:  Journ.  Am.  Med.  Assn.,  September,  1913,  p.  770. 

2  Bigelow:  Boston  Med.  and  Surg.  Journal,  1858,  vol.  Iviii,  p.  99. 


Fracture  of  outer  portion  of  radius; 
a;-ray  tracing. 


CHAPTER  XXI. 

FRACTURES  OF  THE  CARPUS  AND  HAND. 

Fractures  of  the  Carpus,  of  the  Metacarpal  Bones,  and  of  the  Phlanges. 

1.  FRACTURES  OF  THE  CARPAL  BONES.^ 

(See  also  Plates  XXXI-XXXVI.) 

The  findings  of  the  .r-rays  in  the  last  decade  and  the  clinical  obser- 
vations which  they  have  stimulated  and  made  possible  have  brought  to 
our  knowledge  in  detail  many  lesions  of  the  carpus  which  were  hereto- 
fore unknown  or  known  only  incompletely  and  as  of  rare  occurrence. 
The  anatomical  and  physiological  complexity  of  the  carpus  leads  to  a 
corresponding  complexity  of  the  traumatic  lesions  which  occur  in  it 
and  of  the  combinations  which  may  be  produced  in  accordance  with 
the  many  variations  in  the  direction,  extent,  and  prolongation  of  the 
force  which  produces  them.  Fractures  and  dislocations  of  the  different 
bones  which  compose  the  carpus  may  occur  singly  or  in  various  com- 
binations, and  while  some  of  the  single  injuries  and  some  of  the  combi- 
nations occur  frequently  and  regularly  enough  to  justify  systematic 
description,  others  are  so  few  or  so  variable  and  so  dependent  upon 
varying  mechanical  conditions  that  they  defy  analysis  and  classification 
and  must  be  recorded  only  as  isolated  facts. 

The  two  most  frequent  lesions  are  fracture  of  the  scaphoid  and  dis- 
location of  the  semilunar.  Of  each  of  these  many  clear  uncomplicated 
instances  have  been  observed,  and  yet  the  two  are  not  infrequently 
C()ml)ined,  and  often  in  association  with  various  derangements  of  the 
mutual  relations  of  the  other  bones,  in  such  a  way  as  to  lead  some  in- 
vestigators to  believe  that  this  combination  should  be  regarded  as  the 
type,  and  the  freqtient  lesser  individual  injuries  as  minor  forms  of  or 
deviations  from  it.  Thus,  a  frequent  combination  is  fracture  of  the 
scaphoid  with  dislocation  forward  of  the  proximal  fragment  together 
with  the  semilunar  and  a  displacement  backward  of  the  os  magnum 

•  Bibliography.— Letenneur,  Bull  de  la  See.  Anat.,  1839,  vol.  xiv.  p.  162;  Gulbout 
ibid.,  vol.  xxii.  p.  27-  Flower,  Holmes's  Syst.  of  Surg.,  Am.  ed.,  vol.  i.  p.  867-  Fortu- 
ne t,  Lyon  Med.,  July  1,  1888;  Rutherford,  Glasgow  Med.  Jour.,  1891,  p.  312;  Stimson, 
N.  Y.  Med.  Jour.,  May  21,  1892;  Auvray,  Gaz.  des  H6p.,  1898,  p.  377  ;  Sir  Wm.  Stokes, 
British  Med.  Jour.,  1900,  i.  p.  1075;  Hofiiger,  Corre.sp.-blatt.  fiir  Schweiz.  Aerzte,  1901, 
p.  297;  Kaufman,  Ibid.,  1902,  p.  257;  Stimson,  Annals  of  Surg.,  May,  1902;  Pagen- 
stecher  Miinch.  Med.  Wochenschrift,  1903,  p.  1916 ;  Wolff",  Deutsche  Zeitschrift  fiir 
Chir.,  1903,  vol.  Ixix.  p.  401;  Blau,  Ibid.,  vol.  Ixxii.  p.  445;  Lilienfeld,  Arch,  fiir 
khn.  Chir.,  1903;  vol.  Ixix.  p.  1158;  Vialle,  Arch,  de  Med.  and  Phar.  Med.,  Oct.,  1904; 
Russ.  Annals  of  Surg.,  Feb.,  1905;  Codman  and  Chase,  Annals  of  Surg.,  March  and 
June,  1905,  an  elaborate  paper;  Karrer,  Inaug.  Diss.,  Kiel,  1905,  abst.  in  Zentralblatt 
fur  Chir.  1906,  p.  811;  Ehebald,  Arch,  fur  Orthopsdie,  Mechanother.  und  Unfallchir., 
1906,  p.  276,  with  bibliography;  Hirsh,  Ztlblatt  fiir  Chir.,  1906,  p.  1289;  Cartruccio, 
Beitrage  zur  kiln.  Chir.,  Feb.' 1907,  p.  66;  De  Quervain,  Monatschrift  fiir  Unfallheil- 
kunde,  1902,  vol.  9,  p.  65 ;  Ebermaver,  Fortschritte  aus  dem  Geb.  Roentgenstrahlen, 
1908,  vol.  12;  Shoch.  Deut.  Ztschri'ft,  fiir  Chir.,  1907-8,  vol.  91,  p.  53;  Delbet,  Bull,  et 
Mem.  de  la  Soc.  de  Chir.,  1908 ;  vol.  34,  p.  377;  Downes,  Annals  of  Surg.,  Jan.,  1908; 
Ely.  Med.  Record,  May,  1908. 

(  335  ) 


336 


FRACTURES. 


either  from  its  fellows  of  the  seciHid  row  of  the  carpus  or  with  them 
from  the  remaining  bones  of  the  first  row.  Delbet/  in  an  elaborate, 
pathological,  clinical,  and  experimental  study  of  the  subject,  proposes 
that  this  injury  should  be  termed  "  dislocation  of  the  os  magnum," 
with  sub-titles  indicating  the  varieties.  The  name  "  dislocation-frac- 
ture of  the  carpal  bones,"  or  "  of  the  intercarpal  joint "  was  suggested 
by  De  Queryain.^  While  the  existence  of  this  complex  type,  and  even 
its  coni])arative  frequency,  cannot  be  questioned,  yet  I  am  convinced  that 
both  fracture  of  the  scaphoid  and  dislocation  of  the  semilunar  occur 

Fig.  223. 


Fracture  of  scaphoid  and  possibly  of  radius. 

without  complications,  or,  in  the  case  of  the  semilunar,  -with  only  slight 
ones,  and  that  the  comprehension  of  the  subject  and  the  readiness  of 
recognition  of  the  injury  will  be  promoted  by  separate  descriptions. 
The  complex  form  will  be  considered  in  Chapter  XLVIIL,  "  Midcarpal 
fracture-dislocation." 

Scaphoid, — Until  within  a  few  years  the  injury  was  deemed  very 
rare,  and  was  known  only  by  a  few  reported  cases  and  fresh  specimens 
obtained  at  autopsy  or  by  operation,  and  a  few  museum  specimens  of 

1  Delbet :  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  1908,  Tol.  xxxiv.  p.  377. 
"^  De  Quervain  :  Monatsclift  fiir  Unfallheilkunde,  1902,  vol.  ix.  p.  65. 


FRACTURES  OF  THE  CARPUS  AND  HAND. 


337 


old  fractures  obtained  by  chance,  of  some  of  which  it  was  claimed  that 
thev  might  be  examples  of  a  rare  developmental  variation,  the  ''  navic- 


Fifi.  230. 


Fracture  of  the  scaphoid,  with  displacement  of  proximal  fragment. 


Fig.  231. 


Fracture  of  scaphoid.     Profile  view  of  Fig.  230. 


ulare  l)ipartitiim."     After  the  existence  of  the  fresh  fracture  had  been 
shown  by  the  a;-rays  and  the  clinical  recognition  had  become  easy  the 


338 


FRACTURES. 


number  of  reported  cases  rapidly  increased  and  its  frequency  is  now 
well  established.  Doubtless  cases  were  previously  thought  to  be  sprains 
or  occasionally  Colles's  fracture,  or  were  overlooked  when  they  co-ex- 
isted with  the  latter  injury. 

The  injury  is  most  frequent  in  males  between  the  ages  of  twenty  and 
forty  years.  The  common  cause  is  violence  received  upon  the  ball  of 
the  thumb,  while  the  wrist  is  in  dorsal  flexion,  by  which  the  scaphoid 
is  pressed  directly  against  the  radius.  Usually  it  is  by  a  fall  upon  the 
outstretched  hand,  but  in  a  few  cases  the  violence  has  been  received  in 
a  manner  which  is  identical  with  that  in  which  the  lesion  has  been 
often  produced  in  experiments,  namely,  a  blow  or  forcible  pressure 
against  the  ball  of  the  hand  iu  the  direction  of  the  long  axis  of  the 

Fig.  232. 


Fracture  of  carpal  scaphoid. 


forearm  while  the  back  of  the  elbow  rests  against  solid  resistance.  The 
few  reported  cases  in  which  the  scaphoid  has  been  broken  in  forced 
flexion  of  the  wrist  apparently  belong  in  the  complex  form,  the  "  frac- 
ture-dislocation." The  character  of  the  violence  is  so  similar  to  that 
which  produces  Colles's  fracture  that  the  two  may  probably  be  deemed 
alternative  lesions,  the  scaphoid  ]:)reaking  in  some,  the  radius  iu  others, 
especially  the  old  whose  epiphyses  are  thinned.  This  is  further  con- 
firmed by  the  fact  that  occasionally  the  two  fractures  co-exist. 

The  mechanism  of  the  fracture  is  not  clear.  Various  explanations 
have  been  oflPered,  some  of  which  can  be  true  only  of  the  complex  cases 
and  will  not  here  be  considered.  (See  ]Midcarpal  Fracture-Dislocation.) 
Of  the  others,  two  seem  possible:  pressure  by  the  head  of  the  os  mag- 
num against  the  proximal  half  of  the  scaphoid,  and  pressure  by  the 
external  object  against  the  projecting  poles  of  the  ciu-ved  bone,  as  a 


FRACTURES  OF   THE  CARPUS  AND  HAND.  339 

curved  rod  is  broken  by  straightening  it.  The  latter  seems  the  prob- 
able cause  in  cases  in  which  the  fracture  is  in  the  distal  two-thirds  of 
the  bone  and  the  displacement  slight.  In  the  cases  in  which  the 
proximal  fragment  is  dislocated  forward,  pressure  by  the  head  of  the 
OS  magnum  is  apparently  the  only  agency  by  which  the  displacement 
could  be  effected,  and  it  is  probable  that  it  would -have  a  part  in  pro- 
ducing the  fracture.  Unquestionably  in  these  cases  with  dislocation 
of  the  fragment  there  must  have  been  at  the  moment  of  dislocation 
some  shift  in  the  relations  of  some  of  the  other  carpal  bones  to  one 
another,  a  fact  which,  strictly  speaking,  would  bring  them  within  the 
complex  class,  but  the  shift  is  either  temporary  or  so  slight  as  to  be 
unrecognizable  either  clinically  or  by  the  .r-rays,  and  I  therefore  prefer 
to  group  them  with  the  pure  fractures. 

It  seems  probable  that  the  issue  of  the  production  of  a  Colles's  frac- 
ture, a  fracture  of  the  scaphoid,  or  a  "fracture-dislocation  "  is  determined 
by  the  direction  in  which  the  force  is  applied  to  the  limb  and  the  posi- 
sition  of  the  hand.  If  the  hand  is  bent  backward  but  little  beyond 
straight  extension,  as  is  common  in  a  fall  upon  it,  the  force  acts 
obliquely  to  the  line  of  the  radius  and  breaks  it  across — Colles's ;  if  the 
hand  is  thrown  further  back  and  the  force  is  more  in  the  line  of  the 
forearm,  the  lower  end  of  the  radius  is  crushed — another  form  of 
Colles's — or  the  scaphoid  is  broken  ;  if  the  force  is  received  a  little 
further  out  on  the  palm  of  the  hand  and  exaggerates  its  dorsal  flexion, 
the  head  of  the  os  magnum,  which  has  moved  around  to  the  back  of 
the  semilunar,  forces  the  latter  out  of  place,  taking  with  it  generally  a 
part  of  the  scaphoid,  and  permanently  changes  the  relations  of  other 
bones — "fracture-dislocation." 

The  line  of  fracture  is  transverse  and  generally  nearer  the  proximal 
than  the  distal  end  of  the  bone,  within  the  area  of  articulation  with  the 
OS  magnum  ;  very  rarely  are  there  more  than  two  pieces.  The  separa- 
tion of  the  fragments  is  shown  by  the  .arrays  to  be  increased  by  ulnar 
flexion  and  diminished  by  radial  flexion  of  the  hand.  Failure  of  union 
is  frequent  and  is  probably  constant  in  fracture  near  the  proximal  end 
where  the  line  of  fracture  is  wholly  or  mainly  intracapsular  ;  in  the 
distal  portion  the  fracture  may  leave  the  blood  supply  sufficient  for 
repair.  In  the  cases  in  which  union  is  thought  to  have  occurred  the 
opinion  has  been  based  on  the  relief  of  symptoms  and  the  .T-ray  find- 
ings, neither  of  which  is  entirely  sufficient.  The  associated  lesions  that 
have  been  observed  are  Colles's  fracture  of  the  radius,  fracture  of  the 
styloid  process  of  the  radius,  and  forward  dislocation  of  the  proximal 
fragment  of  the  scaphoid. 

The  characteristic  symptom,  upon  which  the  diagnosis  can  be  made 
with  great  certainty,  is  sharp  pain  on  pressure  in  the  depression  between 
the  extensors  of  the  thumb,  the  "anatomical  snuft'box."  INIurphy  says 
that  pressing  the  3d  metacarpal  upward,  and  to  a  less  extent  the  1st 
and  2d,  causes  pain.  There  is  no  definite  deformity  except  swelling; 
function  is  lost  or  much  impaired  because  of  ])ain.  If  the  proximal 
fragment  is  displaced  forward  it  can  be  plainly  felt  on  the  i)almar 
aspect  of  the  wrist  at  about  the  level  of  the  styloid  process  of  the  radius. 


340  FRACTURES. 

As  time  passes,  with  or  without  treatment,  the  pain  diminishes,  but 
only  to  return  sharply  after  some  unguarded  forcible  movement.  These 
recidives  are  thought  by  some  to  be  characteristic  of  the  injury. 

The  diagnosis  in  fresh  cases  is  made  by  the  history,  loss  of  function, 
and  pain  in  the  tabatiere  ;  in  older  cases  by  the  same  local  pain,  the  long 
persistence  of  disability,  and  the  absence  of  characteristic  signs  of  other 
injury  or  disease.      Confirmation  by  the  a:-rays  is  desirable. 

The  prognosis  is  rather  unfavorable.  At  the  best  there  is  likely  to 
remain  some  loss  of  flexion  and  extension  in  the  wrist,  and  sometimes 
motion  is  almost  wholly  lost.  There  is  reason  to  hope  that  with  earlier 
recognition  and  suitable  treatment  this  may  be  improved,  for  the  limi- 
tation is  clearly  the  result  of  periarticular  retraction  due  to  the  arthritis 
set  up  by  the  trauma  and  maintained  by  the  presence  of  the  movable 
and  poorly  nourished  fragment.  Many  of  the  observations  upon  which 
our  knowledge  of  the  subject  is  based  have  been  made  in  Zander  or 
mechanico-therapy  establishments  to  which  the  patients  have  gone  for 
treatment  of  the  late  disability,  and  a  number  of  the  specimens  have 
been  obtained  by  the  late  removal  by  operation  in  the  hope  of  relieving 
the  stiifness. 

The  treatment  in  the  fresh  simple  cases  without  displacement  which 
at  present  offers  the  best  prospect  is  immediate  immobilization  for 
about  a  month.  A  number  of  successful  results  in  which  this  means 
has  apparently  been  effective  have  been  published,  while  those  in  which 
passive  motion  and  mechanico-therapy  have  been  employed  have  not 
done  well. 

If  the  proximal  fragment  has  been  dislocated  forward  it  should  be 
removed  through  a  palmar  incision.  Several  such  cases  with  a  good 
result  have  been  reported.     I  have  had  two. 

In  the  old  cases,  with  stiffness,  even  if  pain  is  absent,  both  fragments 
should  be  removed,  and  possibly  the  entire  first  row.  Vallas^  recom- 
mends total  excision  of  the  carpus,  because  in  two  cases  in  which  he 
left  only  the  trapezium  and  trapezoid  the  joint  remained  stiff.  In  a 
personal  case  in  which  the  injury  was  eight  years  old  and  the  joint 
quite  stiff  I  first  removed  both  fragments ;  no  improvement  following, 
I  removed  the  semilunar  and  cuneiform.  On  removal  of  the  dressings 
the  gain  was  slight,  but  increased  under  baking  and  use.  The  patient 
was  then  lost  sight  of.  For  this  excision  of  the  scaphoid  alone  a  dorsal 
incision  just  inside  of  the  long  extensor  of  the  thumb  is  convenient. 

The  semilunar  has  been  found  broken  in  a  few  cases  on  examination 
through  an  open  wound  or  at  autopsy,  under  great  violence  and  with 
associated  injuries  of  the  region.  Under  the  .r-rays  it  has  been  found 
to  present  in  a  number  of  cases  appearances  which  were  thought  to 
indicate  recent  or  remote  fracture.  Ebermayer^  gives  five  such,  in 
only  one  of  which  the  diagnosis  seems  to  me  to  be  beyond  serious  ques- 
tion.    Finsterer^  reports  four   personal   and    thirteen  reported  cases. 

1  Vallas :  Bull,  de  la  Soc.  de  Chir.,  1908.  vol.  xxxiv.  p.  118. 

^  Ebermayer  :  Fortschritte  aus  dem  Geb.  dc  Koeiitgciistrahlen,  1908,  vol.  xii.  p.  1. 

'  Fiusterer:  Beitrage  zur  klin.  Chir.,  vol.  Ixiv.  p.  85. 


FRACTURES  OF   THE  CARPUS  AND  HAND.  341 

He  gives  as  symptoms  shortening  of  the  distance  between  the  base  of 
the  third  metacarpal  and  the  edge  of  the  radius  (a  difficult  measure- 
ment) and  pain  on  pressing  the  metacarpal  bone  u|)\vard.  He  says  the 
prognosis  is  unfavorable  in  respect  of  function,  and  ach'ises  extu-pation 
of  the  bone  to  diminish  the  later  arthritis  and  stiffening. 

Granier^  reports  3  cases,  seen  in  one  year,  of  what  he  terms  com- 
pression fracture,  all  in  young  men,  and  caused  by  a  twist  or  a  fall. 
In  two  there  was  permanent  limitation  of  motion;  the  third  made  a 
good  recovery. 

Plunger  {J]^ien.  klin.  Wochenschrijt,  1914,  No.  33)  reports  2  cases 
caused  by  pressure  against  the  palm  of  the  hand  in  full  dorsal  flexion. 

The  cuneiform  has  been  occasionally  broKen,  either  alone  or  in  con- 
nection with  other  injuries.  The  fracture  may  be  merely  the  avulsion 
of  a  scale  of  bone  or  a  splitting  or  crush  by  compression  in  consequence 
of  a  blow  or  fall  upon  the  hand.  Dinecke  {Deutsche  ZeitschrifL  fur 
Clin.,  1911,  vol.  iii.  p.  413)  reports  three  personal  cases  and  gives  the 
bil)liography. 

The  OS  magnum  has  been  reported  broken  at  the  neck  in  three  cases 
observed  clinically,  and  of  course  some  doubt  must  remain  of  the  accu- 
racy of  the  diagnosis.  The  first  case  was  that  of  Robert,  quoted  as 
doubtful  in  the  Traiti  cle  Giirurgle  of  Le  Dentu  and  Delbet  from  the 
Ann.  de  Tlierapeut'ique  de  Rognetta,  1845,  p.  146.  The  others  are  those 
oUsloty  {Gaz.  des  Hup.,  1890,  p.  63 4 j.  which  seems  accurate  and  of 
Guermonprez,  very  briefly  abstracted  in  the  Iiei:  de  CJiir.,  1882,  p.  81. 
I  have  seen  one  case  in  which  the  possibility  of  fracture  was  suggested 
by  pain  on  pressure  over  the  neck  of  the  bone.  Harrigan  ^  reports  a 
case  confirmed  by  the  .r-rays,  and  two  cases  have  been  reported  in  which 
the  .r-rays  have  shown  the  fracture  associated  with  that  of  other  carpal 
bones.  Ebermayer  gives  a;-ray  pictures  of  a  transverse  fracture  of  the 
unciform,  and  of  avulsion  of  a  small  piece  of  the  trapezium. 

The  pisiform  has  been  reported  broken,  ajjpareutly  by  forcible  con- 
traction of  the  flexor  carpi  uluaris,  by  Alsberg^.  The  surface  of  frac- 
ture was  parallel  to  the  palmar  surface,  dividing  the  bone  into  a  small 
superficial  and  a  larger  deep  fragment,  which  corresjiouds  to  the  in- 
clusion of  the  superficial  portion  in  the  tendon  of  the  flexor  and  the 
ligamentary  attachment  of  the  deeper  portion  to  -the  cuneiform.  The 
diagnosis  was  made  by  the  .r-rays.  The  symptoms  were  local  ])ain  on 
pressure  and  pain  on  forced  ulnar  flexion  of  the  wrist.  Reunion  took 
place. 

Deane  ^  reports  a  case  of  fracture  into  proximal  and  distal  lialvcs  in 
a  man  twenty-one  years  old,  apparently  by  forced  hyperextension  of 
the  wrist.  It  was  verified  by  the  x-rays.  The  only  symptom  was 
crepitus  on  manipulation.     Good  recovery. 

I  have  seen  one  case ;  the  bone  was  broken  into  lateral  halves  by  a 
fall  upon  the  palm,  with  possibly  a  small  third  fragment,  as  shown  by 
the  .T-rays.     Slight  crepitus  and  pain  on  handling  and  on  contracting 

1  Granier:  Deutst-he  Med.  Woehenschrift,  1909,  p.  928. 
-  Harrigan:  Annals   of   Sur<;ery,    Dcr.,    IflOS,    p.   917. 
3  Alsberg:   Zeitsfhrift   fiir  Orthop.   Cliir..    1008,   vol.   xx. 
^  Deane;  Annals  of  Surgery,   1911,  vol.  Jiv.  p.  229. 


342 


FRACTURES. 


the  flexors  of  the  wrist.    There  was  marked  lateral  separation  of  the 
fragments,  which  persisted.     Good  recovery. 

Dr.  Bendell  (personal  communication)  has  seen  a  slight  sprain- 
fracture  of  the  trapezium. 

2.  FRACTURES  OF  THE  METACARPAL  BONES. 

While  simple  fracture  of  a  metacarpal  bone  is  not  a  very  common 
accident,  still  it  is  not  so  rare  as  some  authors  have  inferred  from 
hospital  statistics. 

The  third  and  fourth  are  most  frequently  broken,  the  first  and  fifth, 
least.  Simultaneous  fracture  of  two  or  more  is  frequent  when  the 
injury  is  compound. 


Fig.  2.33. 


Fig.  234. 


Fracture  of  first  metacarpal. 


Fracture  of  first  metacarpal. 


A  very  few  cases  of  probable  separation  of  the  epiphysis  have 
been  recorded,  one  by  Malgaigne,  one  by  Hamilton,  and  one  quoted 
by  Polaillon  from  a  thesis  by  Pichon,  the  ages  being  nine,  eight,  and 
twelve  years  respectively.  There  was  failure  of  union  in  Malgaigne's 
case,  but  without  disturbance  of  function  when  last  seen,  thirteen  years 
after  the  injury.  Separation  of  the  epiphysis  of  the  1st  metacarpal 
(which  is  at  the  proximal  end,  not  at  the  distal,  as  in  the  others)  has 
been  reported  in  a  few  cases  (Coues,  Annals  of  Surg.,  1912,  Ixi,  450; 
Gasne,  Rev.  crOrthoped.,  1913,  No.  3).  The  latter  saw  also  2  of  the  3d 
and  1  of  the  4th.    Bennett^  described  a  varietv  of  fracture  of  the  base 


1  Bennett:  British  Medical  Journal,  July,  1886,  p.  13. 


FRACTURES  OF   THE  CARPUS  AND  HAND.  343 

of  the  first  metacarpal,  an  oblique  fracture  by  which  the  palmar  half 
of  this  end  is  separated  and  the  remainder  is  displaced  more  or  less 
backward,  so  that  at  first  sight  the  injury  appears  to  be  a  subluxation. 
He  collected  nine  examples.  The  usual  displacement  is  angular,  the 
apex  of  the  angle  being  directed  backward  or  forward,  and  at  the  same 
time  the  fragments  may  override  longitudinally.  J\Iiles  and  Struthers 
(Edinb.  Med.  Journal,  April,  1904)  observed  ten  cases  in  four  years, 
and  Russ  (Jour.  Avi.  Med.  Assoc,  1906,  vol.  xlvi,  p.  1S24),  eight  in 
one  year.  I  have  seen  a  similar  fragment  broken  from  the  radial  side 
of  the  base  by  a  blow  with  the  fist. 

Cause.  The  cause  may  be  direct  or  indirect  violence.  When  direct 
it  is  a  blow  upon  the  back  or  even  the  palm  of  the  hand,  a  fall  or 
blow  upon  its  side,  or  a  crushing  force,  the  hand  being  caught  between 
two  solid  bodies.  The  first,  second,  and  fifth  metacarpals  are  the  ones 
most  frequently  broken  by  direct  violence. 

The  commonest  indirect  cause  is  violence  received  upon  the  distal 
end  of  the  bone  in  the  direction  of  its  long  axis,  by  which  its  normal 
curve  is  exaggerated  and  fracture  produced,  as  in  a  fall  upon  the 
knuckles  or  a  blow  with  the  fist. 

Symptoms.  The  symptoms  are  the  deformity  due  to  the  displace- 
ment of  the  distal  fragment,  abnormal  mobility,  crepitus,  pain,  and 
inability  to  use  the  fingers.  The  deformity  is  usually  slight  and  may 
be  wholly  masked  by  the  swelling ;  abnormal  mobility  and  crepitus 
may  be  found  by  flexing  and  extending  the  corresponding  finger  and 
at  the  same  time  making  pressure  upon  the  palm  at  the  supposed  seat 
of  fracture,  so  as  to  make  the  fragments  prominent  behind.  The  pain 
can  be  suddenly  and  sharply  increased  by  pressing  the  finger  toward 
the  carpus. 

The  course  of  the  fracture  is  usually  simple,  and  ends  in  consolida- 
tion in  the  course  of  three  or  four  weeks.  The  complications  which 
occurred  in  the  eighty-one  cases  collected  by  Polaillon  were  inflamma- 
tion of  the  carpo-metacarpal  joint,  union  with  marked  displacement, 
fusion  of  adjoining  bones  when  both  were  broken,  and  deviation  of 
the  extensor  tendons  by  a  voluminous  callus  in  one  each,  and  failure 
of  union  in  three.  In  neglected  cases  of  fracture  at  or  near  the  knuckle 
suppuration  is  not  infrequent  and  may  so  extend  as  to  cause  marked 
disability. 

Treatment.  The  first  indication  is  to  prevent  a  too  severe  inflam- 
matory reaction  if  it  threatens,  and  with  this  object  the  hand  should 
be  kept  at  rest  in  an  elevated  position. 

If  there  is  no  displacement  or  tendency  thereto,  a  simple  immobil- 
izing dressing  of  cotton,  bound  on  snugly  with  a  roller-bandage,  is  suf- 
ficient, the  fingers  being  left  free  to  prevent  their  stiffening. 

A  method  that  has  long  found  favor  is  to  fill  the  palm  with  a  mass 
of  tightly  packed  cotton  or  some  similar  substance,  or  a  ball,  over 
which  the  fingers  are  closed  and  fastened  down  with  a  bandage  or 
adhesive  plaster.  The  flexion  of  the  finger  over  the  firm  mass  tends 
to  draw  the  knuckle  downward,  and  thus  prevent  shortening.  The 
support  furnished  by  the  adjoining  bones  is  an  additional  aid  against 


344  FRACTURES. 

displacement,  and  the  back  of  the  hand  can  be  left  partly  uncovered 
for  inspection. 

In  fracture  of  the  third  and  fourth  metacarpals  the  hand  may  be 
bound  upon  a  dorsal  or  palmar  longitudinal  splint  suitably  padded  and 
fastened  with  a  roller,  but  this  plan  is  unsuited  to  fractures  of  the 
second  or  fifth  because  the  circular  compression  exerted  by  the  bandage 
tends  to  cause  lateral  displacement. 

If  continuous  traction  seems  necessary  to  overcome  a  tendency  to 
displacement  the  finger  may  be  bound  to  the  adjoining  ones  for  a  few 
days,  but  it  is  important  that  immobilization  of  the  fingers,  especially 
in  the  extended  position,  should  be  avoided  or  made  as  brief  as  pos- 
sible. 

In  Bennett's  fracture  of  the  first  metatarsal  reduction  is  made  by 
strong  traction  and  pressure  against  the  base  of  the  bone ;  maintenance 
by  splints  and  adhesive  plaster  or  by  plaster  of  Paris. 

3.  FRACTURES  OF  THE  PHALANGES. 

These  fractures  are  usually  due  to  direct  violence,  and  in  conse- 
quence are  frequently  compound  or  at  least  accompanied  by  laceration 
or  bruising  of  the  soft  parts.  A  few  cases  have  been  reported  of  frac- 
ture by  indirect  violence,  as  in  a  fall  or  blow  upon  the  end  of  the 
finger,  or  by  having  the  finger  caught  and  fixed  while  the  hand  con- 
tinued to  move. 

The  proximal  phalanx  is  the  one  most  frequently  broken,  the  ter- 
minal phalanx  most  rarely. 

The  symptoms  upon  which  the  diagnosis  is  made  in  simple  fractures 
are  mobility  and  crepitus. 

The  progress  of  the  case  in  simple  fracture  is  toward  prompt  repair ; 
in  compound  fractures  the  suppuration  is  apt  to  be  prolonged,  and 
necrosis  of  splinters  and  even  of  one  of  the  principal  fragments  is  not 
uncommon. 

A  well-established  rule  of  treatment  of  injuries  of  the  hand  is  to 
save  everything  that  can  be  saved,  but  it  needs  limitation  in  compound 
fractures  of  the  fingers.  While  it  is  desirable  to  save  the  thumb  or 
any  part  of  it,  even  at  the  price  of  anchylosis  of  both  the  joints,  the 
same  value  does  not  attach  to  the  fingers,  and  a  rigid  deformed  finger 
that  has  been  saved  with  much  difficulty  is  often  a  source  of  so  much 
inconvenience  that  the  patient  subsequently  seeks  relief  in  amputation. 
It  is  better  that  members  so  injured  that  rigidity  will  probably  result 
should  be  removed  at  first,  for  the  attempt  to  save  them  cannot  be 
made  without  incurring  certain  risks,  prolonged  suppuration,  phlegmon 
of  the  forearm,  tetanus,  which,  although  somewhat  remote,  should  not 
be  lost  sight  of. 

In  the  treatment  of  simple  fracture  the  usual  indication  to  prevent 
displacement  is  habitually  met  by  means  of  a  moulded  palmar  splint 
made  of  pasteboard,  felt,  or  gutta-percha  to  which  the  finger,  slightly 
flexed,  is  made  fast.  This  answers  very  well  for  the  terminal  and 
middle  phalanges,  but  it  does  not  support  the  proximal  one  sufiiciently. 
Sometimes  a  straight  splint  is  used,  sometimes  a  plaster-of-Paris 
bandage. 


FRACTURES  OF  THE  CARPUS  AND  HAXD.  345 

A  common  displacement,  important  to  be  guarded  against,  is  an 
angular  one  with  the  apex  directed  forward  and  caused,  I  think,  by 
the  action  of  the  interosseous  muscles.  The  persistence  of  this  dis- 
placement constitutes  a  serious  inconvenience,  for  it  limits  Hexion  of 
the  metacarpo-phalangeal  joint  and  creates  a  prominence  upon  the 
palmar  aspect  of  the  phalanx,  the  skin  covering  which  may  become  so 
sensitive  that  a  firm  grasp  cannot  be  taken  of  any  hard  object. 

As  a  palmar  splint  docs  not  entirely  pn^vent  this  displacement  I 
prefer  to  close  the  hand  upon  some  firm  cylindrical  body,  a  roller-ban- 
dage for  example,  and  fasten  the  fingers  down  with  strips  of  adhesive 
plaster  applied  longitudinally  along  the  back  of  the  hand,  the  fingers, 
and  the  front  of  the  forearm,  and  additionally  secured  with  a  few  turns 
of  a  bandage.  The  roll  must  l)e  large  enough  to  give  ample  support, 
and  by  passing  the  finger  along  the  dorsum  of  the  ])halanx  the  occur- 
rence of  displacement  can  l)e  recognized.  It  will  be  remembered  that 
the  tendon  of  each  extensor  muscle  is  attached  to  the  base  of  the  prox- 
imal phalanx  by  a  short  band  which  limits  the  action  of  the  muscle  to 
that  phalanx,  and  that  the  extension  of  the  middle  and  distal  pha- 
langes is  accomplished  by  the  interossei,  which  also  flex  the  metacarpo- 
phalangeal joint  and  are  relaxed  Avhen  the  fingers  are  closed.  The 
tendency  to  overriding  is  thus  effectively  opposed  by  this  position,  and 
the  displacement  which  then  most  needs  to  be  guarded  against  is  the 
one  also  that  is  most  readily  detected,  angular  displacement  with  the 
angle  directed  backward.  - 

In  compound  fractures  prophylactic  doses  of  tetanus  antitoxin  have 
been  much  used,  and  apparently  with  good  results. 

4.  FRACTURE  OF  THE  SESAMOID  BONES  OF  THE  THUMB. 

Preiser'  reported  a  case  in  which  after  a  fall  the  .r-rays  showed 
transverse  fracture  of  both  sesamoid  bones  of  the  thiunb.  The  i)atient 
recovered  without  reunion  of  the  fragments.  He  was  convinced  by 
the  outline  of  the  fragments  that  it  was  not  simply  a  bipartite  bone, 
and  he  was  able  experimentally  to  produce  the  fractiu'e  by  a  blow  upon 
the  bone.  Three  years  later  Morian-  rei)()rted  another  case,  and 
repeated  the  experiments.  Skillern^  reports  a  case  of  fracture  of  the 
inner  (ulnar)  sesamoid  and  quotes  a  fourth  by  Maas.  The  record 
now  is  one  fracture  of  both  and  three  fractures  of  the  inner  one.  The 
cause  in  all  was  violence  received  directly  against  the  bone,  and  in 
Skillern's  there  was  also  fracture  of  a  ])()rtion  of  the  base  of  the  meta- 
carpal. 

1  Preiser  :  Arzt.licher  Sachverstund,  1907,  p.  400. 

2  Moritm  :  Zoiitrtilblatt  fiir  Chir.,  1910,  p.  423. 
'Skillern:  Annals  of  Surg.,  September,  1915,  j).  297 

25 


CHAPTEK   XXII. 

FRACTURES  OF  THE  PELVIS. 

Fractures  of  the  Ring  of  the  Pelvis,  Sacrum,  Coccyx,  Ilium,  Ischium,  Pubis, 
Rim  of  the  Acetabulum. 

Following  well-founded  custom  I  group  in  one  section  all  fractures 
which  break  the  continuity  of  the  ring  of  the  pelvis  and  consider  sepa- 
rately fractures  of  the  individual  bones  which  do  not  break  the  con- 
tinuity of  the  ring. 

1.  FEACTURES  OF  THE  RING  OF  THE  PELVIS. 

The  most  frequent  cause  of  this  lesion  is  the  passage  of  the  wheel  of 
a  heavily  laden  wagon  across  the  thigh  and  hypogastrium  ;  among  the 
others  are  falls  upon  the  feet  or  the  buttocks,  the  caving  in  of  an 
embankment,  and  crushing  between  the  buffers  of  railway  cars  or 
other  heavy  moving  objects.  The  position  and  the  number  of  the  frac- 
tures vary  with  the  degree  of  the  violence  'and  the  portion  of  the  ring 
upon  which  it  is  received.  When  it  falls  upon  the  symphysis  and  is 
directed  backward  the  arch  yields  at  its  weakest  point,  and  the  line  of 
fracture  passes  through  the  horizontal  and  descending  branches  of  the 
pubis,  sometimes  on  one  side  alone,  sometimes  on  both  sides.  If  the 
force  then  continues  to  act  it  presses  the  vsides  apart,  and  either  breaks 
the  sacrum  vertically  (by  avulsion)  or  ruptures  the  ligaments  of  the 
sacro-iliac  synchondrosis,  or  breaks  the  ilium  into  the  synchondrosis  or 
into  the  sacro-sciatic  notch  ;  and  it  does  this  sometimes  also  on  one  side 
alone,  and  sometimes  on  both. 

When  the  violence  is  received  upon  the  side  of  the  pelvis,  or  the 
great  trochanter,  or  even  upon  the  foot,  it  may  cause  what  Malgaigne 
described  as  double  vertical  fracture  of  the  pelvis,  or  fracture  of  the 
acetabulum  to  a  variable  extent,  and  in  one  case  a  fall  upon  the  foot 
caused  dislocation  of  the  entire  os  innominatum,  separating  it  cleanly 
at  the  symphysis  pubis  and  sacro-iliac  joint  and  forcing  it  upward.  In 
double  vertical  fracture  the  anterior  fracture  occupies  the  same  position 
as  when  the  force  has  been  received  upon  the  symjihysis,  it  crosses  the 
pubis;  the  posterior  one  is  usually  entirely  within  the  ilium  and  behind 
the  acetabulum.  In  fracture  of  the  acetabulum,  which  can  be  caused 
only  by  violence  transmitted  through  the  femur,  the  bone  may  be  simply 
fissured,  or  the  head  of  the  femur  may  be  driven  entirely  through  into 
the  cavity  of  the  pelvis.  In  the  slighter  cases  the  continuity  of  the 
pelvic  ring  is  not  broken,  but  in  the  more  extensive  ones  it  is.  In 
young  people  the  lines  of  fracture  may  follow  those  of  the  develop- 
mental division  of  the  bone  into  three. 
(346) 


FRACTURES   OF   THE  PELVIS.  347 

The  displacenieuts  are  seldom  great,  but  complications  arc  numerous 
and  serious.  The  most  frequent  is  rupture  of  the  urethra,  usually  in 
its  membranous  portion ;  among  the  others  are  rupture  of  the  bladder 
and  laceration  of  the  iliac  veins  or  the  external  iliac  artery.  Rupture 
of  the  bladder  may  be  intra-  or  extra-peritoneal ;  in  some  cases  it 
appears  to  have  been  caused  by  the  direct  pressure  upon  the  bladder  of 
the  object  which  caused  the  fracture,  in  others  by  a  splinter  or  the  dis- 
placed fragment.  The  other  two  lesions  mentioned  are  due  to  the 
displacements.  The  separation  of  the  pubes  tears  the  urethra  across 
at  or  near  the  triangular  ligament,  and  the  projecting  edge  of  the  pos- 
terior line  of  fracture  lacerates  one  of  the  iliac  veins,  or  the  edge  of 
the  anterior  one  tears  the  external  iliac  vein  or  artery. 

In  a  case  briefly  referred  to  by  Legros  Clark  ^  there  were  several 
fractures,  and  separation  of  the  sacro-iliac  synchondrosis  on  each  side 
and  of  the  pubic  symphysis  to  the  extent  of  four  inches.  The  rectum 
was  ruptured  and  feces  were  extra vasated  into  the  pelvis ;  the  bladder 
was  ruptiu'ed  and  the  urethra  torn  completely  from  the  prostate  gland. 

The  varieties  and  the  symptoms,  which  vary  notably  with  them, 
require  separate  mention. 

Separation  of  the  symphysis  pubis  may  be  produced  by  external  vio- 
lence directly  pressing  the  anterior  superior  spines  or  the  ischia  apart 
or  through  forced  abduction  of  the  thighs,  or  by  the  descent  of  the 
foetus  through  the  superior  strait  in  parturition.  Malgaigne  collected 
seventeen  cases  of  the  latter,  most  of  them  occurring  in  primiparse,  and 
most  by  the  unaided  action  of  the  patient's  muscles ;  in  a  few  cases  the 
forceps  was  used.  Usually  the  separation  takes  place  with  a  distinct 
cracking  sound,  and  the  gap  can  be  felt  with  the  finger,  and  in  one  or 
two  cases  the  fracture  has  been  made  compound  by  simultaneous  lace- 
ration of  the  soft  parts.  The  gap  is  the  chief  diagnostic  symptom.  The 
scanty  information  possessed  upon  the  subject  indicates  that,  in  the 
traumatic  cases  at  least,  the  separation  takes  place  not  through  the 
cartilage,  but  between  the  cartilage  and  the  bone. 

The  traumatic  eases  are  no  less  numerous  and  more  varied  in  their 
details,  although  in  a  large  proportion  of  them  the  force  seems  to  have 
been  exerted  through  the  adductor  nuiscles  of  the  thighs.  In  two  cases 
quoted  by  Malgaigne,  in  a  third  reported  by  Weber,^  and  in  a  fourth 
by  Earle,''  the  patient  was  on  horseback  and  received  the  injury  either 
l)y  being  thrown  forward  upon  the  withers,  or  first  to  one  side  and  then 
to  the  other,  or  by  the  muscular  effort  made  to  keep  his  seat.  In  one 
of  Malgaigne's  cases  the  results  were  an  immediate  hernia,  rujiture  of 
the  perineum  with  a  separation  at  the  symphysis  that  would  admit  the 
hand,  and  pain  at  each  sacro-iliac  synchondrosis.  The  })atient  recov- 
ered in  three  and  a  half  months,  the  treatment  consisting  of  a  l)andage 
drawn  tightly  about  the  pelvis,  with  the  limbs  resting  u])on  a  double 
inclined  plane. 

In  Earle's  case  there  were  collapse,  severe  pain,  flattening  of  the 
pubes,  and  free  bleeding  from  the  anus.     An  incision  in  the  perineum 

^  Legros  Clark  :  Diagnosis  of  Visceral  Lesions,  ji.  339. 

2  Weber:  Gaz.  Med.  de  Strasbourg,  1872. 

3  Earle:  Med.  Chir.  Trans.,  1835,  vol.  xix.  p.  257. 


348  FRACTURES. 

gave  exit  to  blood  and  urine.  The  patient  survived  for  only  forty 
hours,  and  the  autopsy  showed  a  separation  of  three  inches  at  the 
symphysis,  the  left  sacro-iliac  synchondrosis  gaping  one  inch,  and  the 
prostate  torn  completely  away  from  the  bladder  and  hanging  down  iii 
a  cavity  filled  with  clot.  The  patient  was  between  sixty  and  seventy 
years  of  age. 

In  another  singular  case  quoted  by  Malgaigne  the  patient,  a  lad 
eighteen  years  old,  was  learning  to  be  a  dancer.  His  teacher  made  him 
lie  upon  his  back  on  the  floor  with  his  thighs  flexed,  and  then  stand- 
ing upon  him  with  one  foot  on  each  knee,  sought  to  force  the  thighs 
outward.  It  caused  the  bones  to  separate  at  the  symphysis  to  the 
extent  of  half  a  finger-breadth. 

Separation  in  Front  and  Behind.  In  one  of  Mr.  Earle's  ^  cases  there 
was  complete  separation  of  the  left  os  innorainatum,  both  in  front  and 
behind ;  the  bone  was  forced  up  to  a  considerable  extent,  and  the  com- 
mon iliac  vein  torn  across.  The  patient  was  a  young  man,  and  received 
the  injury  by  jumping  from  a  third  story  ;  he  landed  upon  the  left  foot, 
causing  also  a  compound  comminuted  fracture  of  the  calcaneum  and 
astragalus. 

Similar  cases  were  collected  by  Malgaigne,  and  two  have  been  pub- 
lished by  Salleron.'  Creite^  reports  one  case  and  collects  seven.  Heine- 
mann"*  reports  two  and  collects  22.  The  injury  has  been  caused  by  a 
fall  upon  one  foot  or  upon  the  side  of  the  pelvis,  or  by  the  pressure 
of  a  heavy  weight  upon  the  front  of  the  pelvis.  The  characteristic 
symptom  is  the  elevation  of  the  corresponding  half  of  the  pelvis  with 
absence  of  the  crepitus  which  is  usually  present  in  double  vertical 
fracture.  Salleron  was  able  to  reduce  the  dislocation  in  his  cases, 
and  both  recovered,  but,  as  a  rule,  the  prognosis  is  extremely  grave. 

Separation  of  the  Sacro-iliac  Synchondrosis.  Simple  separation  of  this 
joint  is  very  rare.  Malgaigne^  quotes  one  case  of  it,  and  four  others  in 
which  there  was  in  addition  fracture  of  the  ilium.  I  have  seen  one  well- 
marked  case.    The  lesion  is  said  also  to  have  been  produced  during  labor. 

The  diagnosis  is  made  by  recognition  of  the  displacement,  which  is 
Dackward  and  outward. 

Separation  of  all  Three  Joints.  A  few^  cases  have  been  reported  as 
such,  but  in  most  there  has  been  also  fracture  at  one  or  mors  points, 
and  the  separation  of  one  or  both  of  the  sacro-iliac  synchondroses  has 
been  only  the  gaping  of  the  joint  due  to  the  lateral  separation  of  the 
two  halves  of  the  pelvis,  and  not  a  real  displacement.  Malgaigne 
quotes  briefly  five  cases,  in  four  of  which  there  were  associated  frac- 
tures of  the  pelvic  bones.  Dolbeau,^  Dubrueil,''  and  Pollock^  have 
since  reported  others.  Dubrueil's  is  the  only  one  in  which  there  seems 
to  have  been  actual  displacement  at  all  three  points,  and  even  in  it 
there  was  also  a  slight  fracture.  The  patient  was  run  over  by  a  wagon. 
There  was  separation  of  two  and  a  half  inches  at  the  symphysis  pubis 

1  Earle:  Loc.   cit.,   p.   261,   Case  5. 

2  Salleron:  Archives  Gen.  de  Med.,  1871,  vol.  ii,  p.  34,  Cases  1  and  2. 

3  Creite:   Deutsche  Zeitschrift  fiir  Chir.,  vol.  83,  p.  391. 
■•  Heinemann:  Arch.  f.  klin.  Chir.,  1913,  vol.   ciii,  No.  4. 

5  Malgaigne:  Loc.  cit.,  vol.  ii,  p.  777.  "  Dolbeau:  Gazette  desHopitaux,  1868  p.  19. 

7  Dubrueil:  Ibid.,  1871,  p.  413.  «  Pollock:  The  Lancet,  1872,  vol.  ii,  p.  409. 


FRACTURES  OF  THE  PELVIS.  349 

aud  gapiug  of  both  sacro-iliac  synchondroses.  The  !?acrum  was  dis- 
placed forward,  projecting  at  the  level  of  the  superior  strait  two  centi- 
metres ill  front  of  the  right  ilium  and  one  and  a  half  in  front  of  the 
left.  There  was  a  fracture  at  the  junction  of  the  right  ischium  and 
pubis,  and  partial  fracture  of  the  body  of  the  right  pubis. 

In  each  case  the  injury  was  caused  by  extreme  violence  acting 
directly  upon  the  pelvis,  the  passage  of  a  heavy  wagon,  the  fall  of  a 
heavy  object.     All  terminated  fatally. 

Fracture  of  the  pubic  portion  of  the  pelvic  ring,  which  is  the  most  com- 
mon of  all,  passes  usually  through  the  horizontal  ramus  just  in  front 
of  the  ilio-pectineal  eminence  and  through  the  descending  ramus  near 
its  junction  with  the  ischium.  The  fracture  may  be  oblique  or  trans- 
verse, may  be  double  (of  one  or  both  pubic  bones),  or  may  be  associated 
with  separation  of  the  symphysis  or  with  other  fractures  of  the  lateral 
or  posterior  portions  of  the  pelvis.  As  has  been  already  mentioned, 
rupture  of  the  ligaments  of  one  or  both  sacro-iliac  synchondroses  with 
gaping  of  the  joint  is  a  frequent  accompaniment  when  the  action  of 
the  fracturing  force  is  momentarily  prolonged. 

The  displacement  is  sometimes  so  marked  that  it  can  be  easily  recog- 
nized by  the  eye  ;  in  other  cases  the  diagnosis  can  only  be  made  after  pal- 
pation of  the  outline  of  the  bone,  which  is  quite  accessible  to  the  touch. 

Interference  with  the  voiding  of  the  urine,  either  by  rupture  of  the 
urethra  or  by  pressure  upon  it,  is  a  frequent  complication.  Injury  to 
the  urethra  takes  place  usually  in  the  membranous  portion.  The 
bladder,  too,  has  been  sometimes  torn  by  a  fragment  or  ruptured  by 
pressure. 

The  following  are  the  more  noteworthy  complications  and  varieties 
that  have  been  recorded.  A  man,  twenty  years  old,  was  run  over  by 
a  railway  train  and  received  a  fracture  of  the  crest  of  the  right  ilium, 
the  ramus  of  the  left  pubis,  and  of  the  "  right  pubis  close  to  its  junc- 
tion with  the  iliac  portion  of  the  bone,  the  sharp  end  of  this  fracture 
had  entirely  divided  the  external  iliac  artery."  ^  A  man,  forty-three 
years  old,  was  run  over  by  a  wagon,  was  brought  to  the  hospital  insen- 
sible, and  died  in  three  hours.  There  was  fracture  of  the  "  ramus  and 
body  of  the  pubis  on  both  sides,  and  separation  of  the  sacrum  from  the 
left  OS  innominatum.  Fracture  of  the  left  ilium,  the  fracture  extend- 
ing across  the  pectineal  line  and  causing  laceration  of  the  left  external 
iliac  vein."  ^ 

Fracture  of  the  lateral  portion  of  the  ring  occurs  in  two  ])rinci|)al 
forms,  one  in  connection  with  fracture  of  the  pubic  portion,  the  other 
a  fracture  radiating  from  the  cavity  of  the  acetabulum.  The  former 
is  the  one  to  which  attention  was  first  called  by  Malgaigne  under  the 
title  o?  double  vertical  fracture  of  the  pelvis,  a  variety  of  wliich  has  been 
described  at  much  length  by  Voillcmier^  as  vertical  fracture  of  the 
sacrum.  The  posterior  line  of  fracture  lies  either  in  the  ilium  entirely 
behind  the  acetabulum,  or  in  the  sacrum,  or  ))artly  in  the  ilium  or 
sacrum  and  partly  in  the  sacro-iliac  synchondrosis,  and  sometimes  the 
sacrum  is  crushed  rather  than  fractured.     The  cause  apparently  may 

1  Lancet,  1878,  vol.  i.  p.  347,  Case  2.  '^  Lancet,  Idem.,  Case  3. 

3  Voillemier  :  Clinique  Chirurgicale,  1862,  p.  77. 


350 


FRACTVRES. 


be  a  force  acting   in   either  antero-posterior  or  transverse   diameter 
of  the  pelvis  or  upward  against  the  tuberosity  of  the  ischium.      The 


Fig.  235. 


^'ci?i:' 


"^ 


'(.  •i^.v 


>^ 


Double  vertical  fracture  of  the  pelvis ;  united. 


most  prominent  symptoms  in  these  cases  are  in  the  position  of  the  leg 
and  in  the  extent  to  which  it  can  be  moved.     The  femur  is  attached 


Fig.  236. 


Double  vertical  fracture  of  the  pelvis  ;  vertical  of  sacrum,  double  of  pelvis. 

to  the  portion  of  bone  which  is  intermediate  between  the  two  lines  of 
fracture,  and  as  this  piece  is  usually  displaced  upward  and  inward 


FRACTURES  OF  THE  PELVIS.  351 

there  is  apparent  shortening  of  the  limb.  At  the  same  time  the  piece 
is  commonly  rotated  abont  an  antero-posterior  axis  so  that  tlie  nj^per  ]mrt 
of  the  pelvis  is  broadened  and  tlie  lower  part  narrowed.  The  inability 
to  move  the  limb  is  due  in  part  to  the  lack  of  a  solid  support  and  the 
fear  of  pain,  and  in  part  perha])s  to  laceration  of  the  muscles  of  the  iliac 
fossa.  Pain  in  the  distril)ution  of  the  obturator  nerve  is  not  uncommon. 
The  prognosis  is  unfavorable  (35  deaths  in  106  cases,  Dreschler)  because 
of  the  probability  of  associated  injuries.  It  may  result  in  lameness 
or  in  a  permanent  change  in  the  shape  of  the  pelvis,  which  in  a  woman 
may  have  serious  consequences  if  pregnancy  should  follow. 

Walther '  describes  a  variation  in  which  the  anterior  fracture  occu- 
pied the  body  and  descending  ramus  of  the  pubis,  and  the  second  frac- 
ture ran  below  the  anterior  superior  spine  of  the  ilium  to  the  sacro- 
sciatic  notch  ;  in  addition  the  upper  fragment  of  the  ilium  was  split 
vertically,  and  the  fifth  sacral  vertebra  was  broken.  The  fragment 
between  the  two  principal  lines  of  fracture  was  displaced  inward  and 
had  reunited. 

The  second  form  of  lateral  fracture  of  the  pelvis,  i-adiating  fracture 
of  the  acetabulum,  and  fracture  of  the  floor  of  the  acetabulum  are  described 
in  the  following  section. 

Vertical  fractures  of  the  sacrum  are  not  known  except  in  connection 
with  fractures  of  the  pelvic  ring  at  other  points,  as  already  mentioned. 
A  few  cases  of  very  extensive  injury  have  been  recorded,  extensive 
crushing  and  multiple  fractures.     All  proved  fatal. 

Course  and  Prognosis.  The  course  and  prognosis  in  all  these  cases 
depend  mainly  upon  the  lesions  associated  with  the  fracture.  The  only 
additional  point  which  requires  mention  is  one  referred  to  by  Legros 
Clark,  the  tendency  to  suppuration  in  the  loose  connective  tissue 
between  the  pubes  and  the  bladder,  especially  after  fracture  of  the 
pubis  or  separation  of  the  epiphysis.  The  uncomplicated  and  simpler 
forms  of  fracture  tend  to  easy  repair,  and  even  fractures  that  are  very 
extensive  are  by  no  means  necessarily  fatal. 

Diagnosis.  The  diagnosis  is  usually  easy,  but  may  be  very  obscure  if 
the  fracture  is  limited  and  without  much  displacement.  The  outline 
of  the  pubis  should  be  carefully  followed  with  the  finger  to  detect  irreg- 
ularity or  localized  pain,  and  pressure  should  be  made  backward  alter- 
nately with  either  hand  upon  the  anterior  portion  of  each  ilium  in  the 
search  for  abnormal  mobility  and  crepitus.  In  vertical  fracture  of  the 
sacrum  or  in  separation  of  the  sacro-iliac  synchondrosis  displacement 
will  change  the  position  of  the  posterior  s})ine  of  the  ilium.  In  double 
vertical  fracture  the  intermediate  portion,  which  bears  the  anterior 
superior  spine,  is  usually  displaced  upward,  and  the  displacement  is 
easy  of  recognition  and  can  be  diminished  or  perhaps  reduced  by  trac- 
tion u])on  the  leg. 

Treatment.  In  cases  without  much  displacement  rest  in  bed  on  the 
back  is  all  that  is  required,  aided  iu  the  multiple  forms  or  in  separa- 
tion at  or  near  the  symphysis  pubis  by  a  stout  girdle  drawn  smigly 
about  the   pelvis.      Reduction  of  a  fragment  of  tlie  pubis   may  some- 

1  Walther:  Soc.  Aiiat.,  October,  1891. 


352  FRAOTUBES. 

times  be  made  by  digital  pressure,  and  that  of  the  intermediate  frag- 
ment in  double  fracture  by  traction  upon  the  limb  aided  by  pressure 
with  the  finger  from  the  yagina  or  rectum.  In  compound  fractures 
loose  fragments  should  be  remoyed. 

Treatment  of  the  complications  belongs  more  properly  to  the  subject 
of  general  surgery,  but  the  frequency  of  laceration  of  the  urethra  and 
the  advantages  of  its  early  recognition  and  treatment  are  so  great  that 
it  deseryes  mention.  On  the  first  indication  of  probable  injury  to  the 
urethra  the  catheter  should  be  introduced,  and  if  its  passage  is  pre- 
vented or  even  rendered  difficult  by  injury  to  the  urethra,  an  incision 
should  be  made  through  the  perineum  to  the  injured  part  cutting  upon 
the  end  of  the  catheter  as  a  guide.  I  have  almost  always  found  the 
membranous  urethra  not  only  torn  across  but  also  so  freely  separated 
by  laceration  of  the  soft  parts  amid  which  it  lies  that  its  recognition 
was  difficult.  It  is  so  thin  and  collapsed  and  its  torn  end  so  shreddy 
that  it  can  hardly  be  distinguished.  For  this  reason  it  is  desirable  to 
make  the  incision  with  the  aid  only  of  local  anaesthesia — cocaine  or 
freezing — in  order  that  the  patient  may  aid  the  recognition  by  passing 
urine.  If  possible  the  two  torn  ends  of  the  urethra  should  be  united 
by  one  or  two  sutures  along  its  roof  so  as  to  aid  the  permanent  resto- 
ration of  the  continuity  of  the  canal;  and  each  torn  end  should  be  split 
for  half  an  inch  along  the  floor  so  as  to  avoid  the  cicatricial  narrowing 
which  follows  circular  division. 

If  the  bladder  has  been  ruptured,  intra-  or  extra-peritoneally,  supra- 
pubic cystotomy  may  be  needed  to  evacuate  the  escaped  urine  and  close 
the  opening  or  for  drainage  of  the  bladder.  Permanent  catheteriza- 
tion through  the  perineal  opening  may  sometimes  take  the  place  of 
suprapubic  drainage;  it  is  not  needed  if  the  bladder  is  uninjured. 

2.  RADIATING  FRACTURE  OF  THE  ACETABULUM  AND  FRACTURE 
OF  THE  FLOOR  OF  THE  ACETABULUM. 

In  the  typical  form  the  first  three  lines  of  fracture  pass  from  the 
acetabulum  across  its  margin  into  the  sciatic  notch,  the  obturator 
foramen,  and  across  the  brim  of  the  pelvis  ;  the  most  frequent  variation 
seems  to  be  the  breaking  off  of  the  pubic  portion  of  the  brim.  An- 
other form  of  fracture,  that  of  the  yfoor  of  the  acetabulum,  seems  to  be  a 
variant  of  the  beginning  of  the  typical  form  and  appears  either  as  a 
slight  splintering  of  the  central  portion  or  a  more  extensive  break  in 
which  the  floor  is  driven  inward  in  several  pieces  the  lines  of  fracture 
of  which  extend  outward  more  or  less  into  the  adjoining  bone. 

As  the  head  of  the  femur  may  be  forced  inward  in  any  of  the  forms, 
pressing  the  fragments  apart,  the  term  luxatio  centralis  femoris  is  fre- 
quently applied  to  them  all,  and  under  that  name  several  articles  treat- 
ing of  the  subject  in  detail,  with  collation  of  reported  cases  have  been 
published.^     The  term  has  also  been  applied,  but,  I  think,  quite  im- 

1  Simon:  Beitrage  zur  klin.  Chir.,  1905,  vol.  45,  p.  555;  Wolff,  Idem.,  1906-7,  vol. 
52,  p.  561,  and  Worner,  Idem,  1907-8,  vol.  56,  p.  185.  See  also  Guibe,  Re\-ue  de  Chir., 
An.  24,  No.  I.,  and  Thevenot,  Idem,  No.  II. 


feactvp.es  of  the  pelvis. 


Fig.  237. 


properly,  to  the  very  exceptioual  form  in  which  the  entire  acetabahim 
is  separated  from  the  rest  of  the  os  innomiuatum  and  displaced  inward. 
Worner  seeks  fnrther  to  restrict  the  term  to  those  cases  in  which  the 
fracture  is  confined  mainly  to  the  acetabulum  and  its  margins,  at  the 
most  breaking  the  pelvic  ring  only  on  the  })ubic  side. 

Typical  form.  In  one  or  two  of  the  typical  class  in  young  patients  the 
lines  of  fracture  have  apparently  followed  the  conjugal  Y-cartilao-e  of  the 
acetabulum.    The  external  iliac  artery  and  vein  have  each  been  torn  once. 

The  injury  has  been  caused  always  by  great  violence  acting  upon  the 
side  of  the  pelvis  and  doubtless  also  on  the  great  trochanter.  Tlie 
patient  is  completely  disabled,  and  it  is  easy  to  recognize  that  the  injury 
is  extensive  and  severe.  The  details  may  be  made  out  by  svstematic 
exploration  of  the  accessible  portions  of  the  pelvis,  including  its  inner 
face  so  far  as  it  can  be  felt  through  the  rectum.  Palpation  within 
Poupart's  ligament  discloses  the  change  in  the  line  of  the  pelvic  riuo-  at 
that  point  and  possibly  the  head  of  tlie  femur  displaced  inward.  The 
finger  in  the  rectum  or  vagina  finds  the  palpable  surface  swollen  and 
tender.  The  great  trochanter  is  sunken,  approximated  to  the  median 
line,  to  an  extent  corresponding  to  the  dis- 
placement inward  of  the  head  of  the  femur. 
Occasionally  there  has  been  bleeding  from 
the  bladder  or  rectum. 

In  the  absence  of  grave  associated  lesions 
the  chances  of  recovery  are  favorable,  under 
immobilization  and  traction  upon  the  thigh, 
with  some  use  of  the  limb. 

A  case  showing  the  possibilities  of  repair 
was  reported  by  Moore.  ^  A  man  received 
a  severe  injury  of  the  hip  thought  to  be  a 
fracture  of  the  neck  of  the  femur;  he  recov- 
ered and  was  able  to  work  with  only  a  slight 

limp.       At   the    autopsy   several    years    later    Head  of  the  femur  driven  through 

the  injury  was  found  to  have  been  a  fracture  '^^  acetabulum. 

of  the  pubis,    iliimi,  and  acetabulum  with 

deep  displacement  inward  of  the  head  of  the  femur  (Fig.  237). 

In  the  second  form,  fracture  of  the  iioor  of  the  ucetabukim,  the  force 
has  apparently  been  received  only  upon  the  trochanter  or  perhaps  along 
the  widely  abducted  thigh.  As  above  stated,  the  lesions  vary  from  a 
splintering  of  the  floor  with  slight  displacement  to  a  crush  in  which 
more  than  half  of  the  floor  with  the  adjoining  margins  is  split  in  sevei'al 
directions  and  turned  back  angularly  by  the  penetrating  head  of  the 
femur.  Apparently  the  pubic  portion  of  the  socket  is  entirely  broken 
through  in  most,  if  not  in  all,  of  these  ca.ses,  the  iliac  and  ischial  portions 
of  the  socket  receiving  little  or  no  injury  beyond  the  limits  of  iho  floor. 
This  readily  explains  the  fiict  that  several  patients  have  been  able  to 
walk  immediately  after  the  receipt  of  the  injury,  the  weight  of  the 
bodv  beins:  transmitted  throudi  the  unbroken  ilium. 

1  Moore :  Medico-Chirurgical  Transactions,  vol.  xxxiv.  p.  107. 


354 


FRACTURES. 


In  the  slight  form,  simple  spliutering  of  the  floor,  it  is  doubtful  if 
a  diagi;iosis  can  be  positively  made,  eveu  with  the  aid  of  the  .r-rays. 

In  the  more  extensive  forms  there  is  loss  of  function  with  preserv- 
ation of  most  of  the  range  on  passive  motion  except  in  abduction. 
There  is  slight  shortening  of  the  limb,  and  flattening  of  the  trochanteric 
region  in  correspondence  with  the  depth  to  which  the  head  of  the  femur 
has  penetrated  and  tenderness  and  fulness  within  the  brim  of  the  pelvis 
over  the  joint,  and  possibly  tenderness  and  swelling  to  be  felt  through 

the  rectum. 

Fig.  238. 


Fracture  of  the  floor  of  the  acetabulum.    A,  before,  B,  after  reductiou.    Reduced 
tracing  from  WoltTs  skiagram. 

By  forcible  traction  outward  at  the  upper  part  of  the  thigh  Wolff 
greatly  reduced  the  displacement  in  one  case  (Fig.  238),  and  got  a 
fairly  good  functional  result.  In  the  other  cases,  in  many  of  Avhich 
even  the  nature  of  the  injury  was  not  fully  recognized  at  first,  the 
patients  recovered  with  considerable  deformity  and  disability. 

Schroeder  {Quart.  Bull.  Nortlnoe stern  3fed.  School,  June,  1909) in  an 
interesting  paper  reports  3  personal  cases  and  collects  46.  In  1  he 
obtained  an  excellent  result;  and  Skillern  and  Pancoast  {Annals  of  Sur- 
gery, 1912,  Iv,  92)  briefly  report  1  recent  and  3  old  cases,  with  skia- 
grams. Vaughan  {Tran^.  Am.  Surg.  Ass.,  1912)  reports  a  case  and 
studies  the  subject  in  detail  on  the  basis  of  about  25  reported  cases. 

3.  TRANSVERSE  FRACTURE  OF  THE  SACRUM. 

This  rare  injury  is  produced  by  blows  or  falls  upon  the  correspond- 
ing region,  and  appears  in  all  cases  to  have  occupied  the  lower  half  of 
the  bone  and  to  have  been  produced  by  the  forcible  bending  inward  of 
its  apex.  Its  direction  is  practically  transverse.  Malgaigne  has 
reported  one  case  of  oblique  fracture ;  in  ic  the  violence  was  received 
upon  the  side  of  the  bone,  and  there  were  also  two  incomplete  trans- 
verse fractures. 

The  usual  displacement  is  an  angular  one,  the  coccyx  and  lower  frag- 
ment being  drawn  forward  so  that' the  apex  of  the  angle  is  directed 
backward  at  the  seat  of  fracture.  The  displacement  is  due  in  part  to 
the  fracturing  force  and  in  part  to  the  action  of  the  attached  muscles. 


PLATE  XXI 


Fracture  of  Acetabulum  and  Displacement  of  Femur  In-ward. 


FRACTURES  OF   THE  PELVIS.  355 

In  a  case  that  came  under  my  observation  at  Bellevue  Hospital  there 
was  extensive  sloiigliing  over  tlie  sacrum  and  denudation  of  the  bone, 
apparently  due  to  the  direct  violence  that  cau.-ed  the  fracture.  The 
same  complication  is  mentioned  in  two  of  the  five  cases  collected  by 
Malwaigne,  both  terminating  fatally. 

Tlie  symptoms  are  :  pain  at  the  seat  of  fracture,  both  spontaneous  and 
provoked  by  pressure  or  movements  of  the  trunk,  or  by  the  act  of  defe- 
cation, or  perhaps  by  the  act  of  coughing ;  the  displacement  if  present ; 
and  abnormal  mobility  and  crepitus  recognized  by  grasping  the  lower 
fragment  between  the  thumb  and  a  finger  introduced  into  the  rectum. 

Agnew^  says  "there  will  probably  be  present  paralysis  of  tlie  blad- 
der and  rectum,  both  of  these  organs  receiving  nerves  from  the  sacral 
plexus,"  and  Losseu^  says  that  when  there  is  complete  displacement  of 
the  fragment  paralysis  of  the  lower  extremities,  bladder,  and  rectum 
is  never  absent,  but  neither  author  quotes  any  cases  in  support  of  the 
statement.  In  the  one  case  that  has  come  under  my  own  observation, 
there  was  almost  complete  paralysis  of  the  lower  limbs,  bladder,  and 
rectum,  which  nine  months  after  the  accident  had  been  recovered  from 
in  great  part. 

In  Bermond's  case,  quoted  by  Malgaigne,  the  fracture  was  near  the 
coccyx,  and  the  lower  fragment  was  displaced  so  far  forward  that  the 
finger  could  not  be  passed  into  the  rectum  until  after  a  female  catheter 
had  been  introduced  as  a  guide.  The  pain  was  extreme,  was  relieved 
by  the  reduction  of  the  displacement,  and  returned  as  soon  as  the  finger 
was  withdrawn. 

Treatment.  Unless  there  is  marked  displacement,  no  treatment  is 
required  beyond  the  use  of  pads  or  rings  to  relieve  the  lower  fragment 
from  pressure.  In  some  cases  the  surgeons  have  sought  to  diminish 
the  pressure  by  flexing  the  thighs  and  supporting  them  upon  pillows 
piled  up  under  the  knees. 

In  two  cases  the  surgeon  has  tried  to  make  direct  pressure  upon  the 
lower  fragment  by  dressings  introduced  into  the  rectum.  Judes,  quoted 
by  Malgaigne,  used  a  cylinder  of  wood  five  inches  long  and  one  inch  in 
diameter  with  graduated  compresses  outside  and  a  T-bandage  to  sup- 
port the  whole.  Bermond  filled  the  rectum  with  a  bag  of  lint,  which 
soothed  the  patient's  pain  but  had  to  be  removed  on  the  following  day 
to  allow  the  bowels  to  be  emptied.  He  then  used  a  shirted  canula 
through  which  the  gas  and  feces  could  be  passed  at  will  while  the  rec- 
tum was  kept  distended  by  the  tampon.  It  was  removed  temporarily 
on  the  seventh  day,  and  finally  on  the  nineteenth,  when  abnormal 
mobility  could  no  longer  be  detected. 

4.  FRACTURE  OF  THE  COCCYX. 

There  is  but  little  definite  knowledge  concerning  this  lesion.  The 
first  mention  of  it  appears  to  be  that  of  Clotpiet  in  the  statement  that 
when  in  old  people  union  has  taken  place  between  the  difierent  por- 
tions of  the  coccyx,  and  between  it  and  the  sacrum,  the  coccyx  miglit 
be  broken  by  a  fall  upon  the  buttocks  or,  as  in  a  case  which  he  had 
seen,  by  a  kick  upon  the  same  part.     He  refers  also  to  another  case  in 

» Agnew :  Surgery,  p.  922.  '^  Lessen :  Deutsche  Chirurgie,  Lief.  65,  p.  7. 


356  FRACTURES. 

which  caries  of  the  coccyx  followed  its  fracture,  but,  as  Malgaigne 
says,  it  does  not  appear  that  Cloquet  verified  the  fracture.  Within  a 
few  years  several  cases  have  been  published,  and  it  is  furthermore  pos- 
sible that  some  of  the  cases  described  as  dislocations  of  the  coccyx  or 
coccygodynia  may  have  been  fractures.  None  of  these  cases  of  fracture 
mentioned  has  been  described  with  any  details,  and  there  is,  there- 
fore, nothing  to  be  said  except  that  the  diagnosis  must  be  made  as 
after  fracture  of  the  sacrum,  and  that  probably  no  treatment  would  be  re- 
quired except  to  reduce  displacement.  (See  Dislocations  of  the  Coccyx.) 
Jollv^  reported  a  unique  case  of  escape  of  the  lower  segment  of  the 
coccyx  through  the  anus  ten  days  after  delivery,  the  bone  apparently 
having  been  broken  at  that  time. 

5.  FRACTURE  OF  THE  ILIUM. 

Fractures  of  the  expanded  upper  portion  of  the  ilium  are  compara- 
tively frequent  and  vary  widely  in  their  position  and  extent ;  the 
more  extensive  ones  pass  transversely  or  obliquely  from  before  back- 
ward at  some  distance  below  the  crest  and  are  associated  sometimes 
with  vertical  lines  which  divide  the  upper  fragment  into  two  or  more 
portions.  Malgaigne  says  that  when  the  fracture  lies  near  the  crest  it 
begins  commonly  at  a  triangular  prominence  on  the  crest  near  its 
middle,  and  runs  thence  backward  or  forward,  or  in  both  directions, 
following  a  curved  line  the  concavity  of  which  is  directed  upward. 
The  fracture  may  be  limited  to  a  small  portion  of  the  rim  of  the  bone, 
as  the  anterior  superior  spinous  process  or  the  outer  lip  of  the  crest. 
In  a  unique  case  observed  by  Hamilton,  the  posterior  superior  spinous 
process  was  broken  oif  by  a  fall  upon  the  back;  and  Riedinger  and 
Linhart^  have  shown  experimentally  that  the  anterior  inferior  spinous 
process  can  be  torn  oif  by  putting  the  Y-ligament  of  the  hip-joint 
upon  the  stretch.  In  a  case  reported  in  the  Bulletins  de  la  Societe 
Anatomique,  1867,  p.  283,  the  anterior  superior  and  inferior  spinous 
processes  were  broken  off  while  still  in  the  condition  of  epiphyses  by 
the  passage  of  a  wagon.     The  patient  was  fifteen  years  old. 

The  displacement  is  usually  slightly  outward,  and  forward  when  the 
line  of  fracture  is  below  the  anterior  superior  spine.  Fragments  of 
the  crest  alone  may  be  markedly  displaced  upward,  and  after  fracture  of 
the  anterior  superior  spine  the  fragment  may  be  displaced  downward. 

Cause.  The  cause  was  formerly  thought  to  be  direct  violence 
exclusively,  but  Hamilton  reported  a  case  of  fracture  by  muscular 
action  separating  a  piece  of  the  crest  three  inches  long  and  including 
the  anterior  superior  spinous  process.  Nickerson^  reported  another 
of  the  anterior  superior  spine  with  abstracts  of  four  additional  cases, 
^Yhitelocke^  two  others  in  lads  eighteen  and  nineteen  years  old  while 
running,  and  Albertiu'^  and  Reverdin*^  similar  ones.  Auer'^  reports  one 
caused  by  kicking  at  and  missing  a  football. 

1  Jolly:   Medical  Record,  Dec.  17,  1887. 

2  Linhart:  Langenbeck's  Archiv,  vol.  xx,  p.  4.51. 

^  Nickerson:   Deutsche  med.  Wochenschrift,  March  6,  1S90. 

■•  Whitelocke:  Lancet,  November  2.5,  1893. 

'  Albertin:  La  Province  Medicale,  1887,  pK  741. 

^  Reverdin:   Centralblatt  fiir  Chirurgie,  1900,  p.  352, 

'  Auer:  Journ.  Am.  Med.  Agsju-,  1913,  p.  1535. 


FRACTURES  OF   THE  PELVIS.  357 

Symptoms.  The  usual  signs  of  pain  and  swelling  are  increased  by 
the  associated  bruising  of  the  overlying  soft  parts ;  abnormal  mobility 
and  crepitus  can  be  felt  on  munipidation  at  times,  but  their  manifesta- 
tion depends  upon  the  position  of  the  fragment,  the  posture  (jf  the 
patient,  and  the  contraction  or  relaxation  of  the  muscles.  In  a  case 
under  my  care  where  a  large  fragment  composed  of  the  anterior  half 
of  the  crest  and  the  adjoining  bone  had  been  broken  off  by  a  fall, 
mobility  and  crepitus  would  at  times  disappear  entirely,  apparently  in 
consequence  of  slight  changes  in  the  position  of  the  fragment.  In 
seeking  for  mobility  and  crepitus  the  abdominal  muscles  should  be 
relaxed  by  bending  the  body  forward  and  to  one  side,  and  the  thighs 
should  be  flexed  on  the  pelvis. 

The  patient  is  usually  unable  to  walk,  because  of  pain  or  of  the 
sense  of  a  lack  of  support. 

Course.  The  course  is  usually  a  simple  one,  and  the  patients  are 
sometimes  able  to  leave  their  beds  in  two  or  three  weeks.  In  some 
very  exceptional  cases  where  the  violence  has  been  extreme  fatal 
injury  has  been  done  to  the  viscera,  such  as  perforation  of  the  intes- 
tines'by  a  splinter  or  laceration  of  the  iliac  veins ;  and  suppuration 
has  sometimes  taken  place. 

Treatment.  The  treatment  is  simple,  rest  in  bed  in  the  position 
which  gives  most  ease  and  is  most  favorable  to  the  relaxation  of  the 
muscles  which  would  be  likely  to  cause  displacement.  The  attempts 
that  have  been  made  in  the  few  recorded  cases  of  fracture  of  the 
spinous  processes  to  keep  them  in  place  by  pressure  witii  pads  and 
bandages  have  been  entirely  unsuccessful. 

6.  FRACTURE  OF  THE  ISCHIUM. 

This  is  one  of  the  rarest  of  the  fractures  of  the  pelvis.  Malgaigne 
collected  only  six  cases,  and  the  list  has  not  been  since  increased  by 
any  reported  in  detail.  In  some  of  the  cases  almost  the  entire  ischium 
was  broken  oflP,  in  others  only  the  tuberosity.  Experiment  indicates 
that  the  fracture  may  pass  into  the  cotyloid  cavity.  In  three  of  Mal- 
gaigne's  cases  the  cause  was  a  fall  upon  the  buttocks,  the  fourth  was  a 
gunshot  fracture,  the  fifth  was  caused  by  an  explosion,  and  the  sixth 
was  in  a  woman  who  had  recovered  from  a  double  vertical  fracture 
of  the  pelvic  ring  with  a  displacement  that  narrowed  the  inferior  strait 
so  much  that  two  years  afterward  delivery  could  be  effected  only  with 
the  aid  of  forceps,  and  the  ischium  was  broken  in  the  effort.  In  two 
of  the  cases  the  fracture  was  comminuted,  and  in  one  of  them  also 
compound,  in  the  other  the  scrotum  was  lacerated  and  the  urethra 
torn,  presumably  by  violence  received  at  the  same  time  upon  the  peri- 
neum and  not  by  displacement  of  the  bone.  In  the  simple  cases 
there  was  little  or  no  displacement ;  in  the  gunshot  fracture  the  frag- 
ment was  displaced  downward  more  than  t..o  inches  by  the  contraction 
of  the  hamstring  nniscles.  The  displacement  persisted,  but  does  not 
appear  to  have  interfered  materially  with  the  movements  of  the  limb. 
All  except  the  sixth  recovered. 


358  FRACTURES. 

Berry^  reports  a  case  of  fracture  of  a  portion  of  the  tuberosity  by 
muscular  action,  running,  in  a  man,  twenty-three  years  old.  Walking 
was  possible  but  painful.  Three  years  later  he  consulted  Berry  because 
of  persistent  soreness  and  grating  pain  on  certain  movements.  The 
.T-rays  showed  a  large  fragment  lying  on  the  outer  side  of  the  tuber- 
osity.    It  was  removed. 

Mobility  and  crepitus  can  be  recognized  by  manipulation  of  the 
bone,  preferably  with  the  finger  in  the  rectum  or  vagina.  The  severity 
of  the  pain  depends  upon  the  violence  and  the  associated  injuries  and 
makes  it  diiRcult  for  the  patient  to  walk. 

No  treatment  is  required  except  rest  in  l)ed  with  pillows  or  air- 
cushions  so  arranged  as  to  prevent  pressure  upon  the  broken  bone.  If 
the  patient  lies  upon  the  side  the  knees  may  be  kept  flexed  to  relax 
the  muscles  which  are  attached  to  the  ischium. 

7.  FRACTURE  OF  THE  PUBIS. 

In  almost  all  cases  of  its  fracture  the  pubis  is  so  broken  that  the 
continuity  of  the  pelvic  ring  is  destroyed ;  the  cases  in  which  only  one 
ramus  has  been  broken  or  in  which  a  lateral  fragment  has  been  broken 
off  are  extremely  rare,  and  consequently  there  is  but  little  to  be  added 
to  what  has  been  already  said  in  the  first  portion  of  this  chapter.  The 
only  cases  of  this  limited  fracture  of  which  I  have  any  knowledge  are 
one  reported  by  Nivet  and  one  by  Cappelletti.  In  Ni vet's ^  case,  the 
account  of  which  is  not  quite  clear,  there  appears  to  have  been  a  double 
fracture  of  the  descending  ramus,  the  intermediate  piece  was  displaced 
forward  and  had  torn  the  skin  of  the  groin.  In  Cappelletti's^  case  a 
man  jumped  from  a  carriage,  alighting  upon  his  feet  with  one  limb 
widely  abducted.  Six  months  afterward  there  was  still  some  swelling 
at  the  anterior  superior  part  of  the  right  thigh,  and  a  fragment  of  bone 
about  two  and  a  half  inches  long,  and  as  large  as  the  finger  could  be 
felt  there.  Cappelletti  was  convinced  that  this  fragment  was  a  portion 
of  the  descending  branch  of  the  pubis  and  the  ascending  branch  of  the 
ischium  detached  by  muscular  action.  The  pelvis  appeared  to  be  defec- 
tive anteriorly  at  the  point  corresponding  to  the  supposed  original  seat 
of  the  fragment,  there  was  acute  pain  on  pressure  at  the  swelling  and 
at  the  tuberosity  of  the  ischium,  the  patient  walked  limping  and  with 
pain,  and  the  pain  was  increased  by  abduction  of  the  limb. 

8.  FRACTURE  OF  THE  RIM  OF  THE  ACETABULUM. 

This  is  a  lesion  which  sometimes  accompanies  partial  or  complete 
dislocation  of  the  femur  upon  the  pelvis. 

The  upper  and  posterior  portion  of  the  rim  is  the  part  most  fre- 
quently broken,  and  the  accompanying  dislocation  is  commonly  back- 
ward. In  one  of  M'Tyer's  cases*  there  were  two  fragments,  and  in 
Maisonneuve's  case  three,  but  in  this  latter  the  fracture  was  much 

>  Berry:  Journ.  Am.  Med.  Assn.,  1912,  p.  1450. 
2  Nivet:  Bull,  de  la  Societe  Anatomique,   1837,  p.  194. 
'Cappelletti:  Ranking's  Abstract,  1848,  vol.  viii,  p.  91. 
4  M'Tyer:  Glasgow   Medical   Journal,    1830. 


FRACTURES  OF   THE  PELVIS.  359 

more  extensive.  In  another  case  (]M'Tyer)  the  fracture  had  united 
with  but  shght  displacement,  and  the  Hgamentum  teres  was  untorn. 
In  Crile's^  hah'  of  the  rim  was  broken  off  at  its  base,  and  a  piece  broken 
from  the  head  of  the  femur. 

The  symptoms,  when  the  case  first  comes  under  observation,  are  those 
of  simple  dislocation  backward,  and  the  complication  of  fracture  is 
recognizable  only  by  slight  crepitus  felt  on  manipulation  or  during 
reduction  or  by  the  easy  recurrence  of  the  dislocation  after  reduction. 
Sometimes  the  head  of  the  bone  slips  out  of  its  socket  again  as  soon  as 
the  traction  ceases,  in  other  cases  only  after  the  lapse  of  a  few  hours  or 
on  movement  of  the  limb  or  body. 

jNIalgaigne  calls  attention  to  the  necessity  of  making  sure  of  the 
existence  of  a  dislocation,  and  of  not  depending  for  the  diagnosis  solely 
upon  crepitus  and  easy  recurrence  of  the  displacement,  signs  which 
may  accompany  fracture  of  the  neck  of  the  femur. 

The  treatment  should  be  directed  to  the  prevention  of  a  recurrence 
of  the  dislocation  after  its  reduction.  Continuous  traction  gave  me  a 
good  result  in  one  case,  but  theoretically  abduction  and  extension  of  the 
limb  should  be  maintained,  as  the  attitude  most  opposed  to  recurrence. 

1  Crile:  Annals  of  Surgery,   1891,  vol.  xiii,  p.  37.3. 
26 


CHAPTER   XXIIL 

FRACTUEES   OF    THE   FEMUR. 

Fractures  of  the  upper  end :  Head,  neck,  separation  of  epiphysis,  through  the 
trochanter  and  neck,  great  trochanter,  trochanter  minor.  Of  the  sl^ft.  Of 
the  lower  end :  Intercondyloid,  separation  of  epiphysis,  either  condyle. 

The  table  in  Chapter  I.  shows  540  fractures  of  the  femur  in  a  total 
of  14,566  cases  (3.7  per  cent.).  Those  of  the  London  Hospital  for 
twenty-six  years  show  3243  in  a  total  of  51,938,  about  6  per  cent. 
The  Berlin  and  Halle  records,  quoted  by  Gurlt,  show  in  totajs  of  232 
and  97  fractures  of  the  thigh,  76  and  21  of  the  neck  of  the  bone  respec- 
tively. The  records  of  Bellevue  Hospital  for  nine  years,  collated  by 
Dr.  F.  E,  Hyde,^  contained  302  cases  of  fracture  of  the  thigh,  in  which 
the  position  of  the  fracture  was  stated,  divided  as  follows:  neck  61, 
upper  third  (exclusive  of  neck)  34,  middle  third  169,  lower  third  31, 
of  which  7  were  of  the  condyles.  Of  236  fractures  of  the  thigh  recorded 
by  Hamilton,  84  were  of  the  neck,  30  of  the  upper  third,  86  of  the 
middle  third,  and  36  of  the  lower  third. 

Malgaigne's  analysis  of  311  fractures  (104  of  the  neck,  207  of  the 
shaft)  according  to  age  and  sex  is  as  follows : 

Fractures  of  the  Shaft. 

Age.                                                                               Male.  Female. 

2  to  20  years 35  12 

20   "   40       "      .         .         .      ■  .         .         .         .47  6 

40   "   60       " 43  15 

60   "  80       " 20  29 

145  62  =  207 

Fractures  of  the  Neck. 

Age.  Male.  Female. 

4  to  50  years .       9  5 

50   "  60  '    " 9  10 

Above  60      " 30  41 

48  56  =  104 

Eecent  observations  indicate  that  the  proportion  in  this  table  of 
fractures  of  the  neck  in  early  life  is  too  low,  the  cases  probably  having 
passed  unrecognized.      See  below. 


(360) 


1  Hyde :  New  York  Medical  Record,  1875. 


FRACTURES  OF  THE  FEMUR.  361 

1.  FRACTURES  AT    THE  UPPER  END  OF    THE  FEMUR. 

In  this  class  are  in  eluded  fractures  of  the  head,  of  the  neck  of  the 
femur,  separation  of  the  epiphysis,  fractures  of  the  great  trochanter 
and  separation  of  its  epiphysis,  fractures  through  the  trochanter,  and 
fracture  of  the  trochanter  minor. 

A.  Fractures  of  the  Head  of  the  Femur. 

The  only  reported  instances  of  this  very  rare  injury  have  been 
obtained  in  cases  in  which  there  was  also  dislocation  backward  of  the 
head  of  the  bone.  Riedel  (quoted  by  Hoifa)  reported  one,  a  boy  fifteen 
years  old  who  had  been  run  over  by  a  heavy  wagon.  The  dislocated 
head  was  split  by  a  line  of  fracture  which  also  traversed  the  neck  lon- 
gitudinally, and  the  posterior  portion  of  the  rim  of  the  acetabulum  was 
crushed.  The  upper  outer  fragment  and  the  trochanter  were  removed  ; 
the  rest  ^f  the  head  was  returned  to  the  socket.  Healing  with  anchy- 
losis. 

Braun^  reported  a  similar  case,  the  line  of  fracture  running  from  the 
insertion  of  the  ligamentura  teres  to  the  attachment  of  the  capsule. 

Ilolbeck^  collected  5  cases  and  added  one. 

I  showed  to  the  New  York  Surgical  Society^  a  specimen  showing  a 
crush  of  the  anterior  portion  of  the  head  one  inch  long,  half  an  inch 
wide,  and  one-eighth  inch  deep,  caused  evidently  by  impact  against  an 
exostosis  situated  close  behind  the  rim  of  the  acetabulum;  the  injury 
closely  resembled  that  occasionally  produced  in  the  head  of  the  humerus 
in  an  anterior  dislocation  by  impact  against  the  edge  of  the  glenoid 
fossa. 

B.  Fracture  of  the  Neck  of  the  Femur. 

The  opinion  long  held  that  this  was  essentially  an  injury  of  advanced 
middle  life  and  old  age  has  been  modified  by  recent  observations  made 
with  the  aid  of  the  .r-rays.  It  is  now  known  to  be  quite  common  in 
the  young,  having  heretofore  been  largely  overlooked  because  of  the 
comparative  mildness  of  the  early  symptoms.  The  earlier  investigators 
thought  most  of  the  cases  were  separation  of  the  epiphysis  (Hess  36 
out  of  46  cases),  but  that  view  now  appears  to  be  incorrect.  Halden- 
wang^  collected  25  cases  of  fracture  between  the  ages  of  one  and  eighteen 
years  and  only  2  of  separation.  Of  the  25,  15  were  females;  7  were 
ten  years  of  age  or  younger,  and  17  between  ten  and  eighteen  years. 
In  the  majority  the  fracture  was  at  the  base  of  the  neck,  most  of  the 
remainder  in  the  middle  third,  and  Only  one  or  two  close  to  the  head. 
In  only  6  was  the  injury  promptly  recognized  as  a  fracture;  in  the 
others  only  after  the  lapse  of  weeks  or  months  by  the  .r-rays  or  in  the 
course  of  an  operation.    Many  of  the  patients  were  able  to  go  about 

1  Braun:  Arch,  fur  klin.  Chir.,  July  15,  1892. 

2  Holbeck:  Arch.  f.  kUn.  Chir.,  1914,  vol.  cv,  p.  G99. 

3  Stimson:  New  York  Medical  Journal,  August,  1S1S9,  p.  163. 
*  Haldenwang:  Beitriige  zur  klin.  Chir.,  190.S,  vol.  57,  p.  81. 


362  FRACTURES. 

from  the  first,  but  with  considerable  difficulty  and  pain.  All  that 
I  have  seen  have  been  fractures  at  or  close  to  the  base  of  the  neck; 
one  of  them,  a  boy  fifteen  years  old,  who  received  his  injury  by  slipping 
and  falling  on  the  sidewalk,  walked  unaided  to  the  hospital,  a  distance 
of  four  hundred  yards  (Plate  XXII).  The  cause  of  this  partial  main- 
tenance of  function  is  thought  to  be  close  impaction  in  some,  infraction 
rather  than  complete  fracture  in  others,  and  the  thickness  and  toughness 
of  the  periosteiun.  The  causative  violence  in  the  young  is  usually 
slight,  and  in  some  the  absence  of  history  of  violence  suggests  a  pre- 
liminary rachitic  softening. 

In  fractures  in  robust  patients  in  middle  life  the  violence  is  usually 
great. 

In  the  old  the  injury  is  much  more  common  in  women  than  in  men. 

It  is  often  produced,  too,  by  shght  causes,  such  as  a  mistep,  a  stum- 
ble, a  fall  upon  the  knee  or  hip,  and  these  two  facts  taken  together 
indicate  senile  change  in  the  bone  as  a  markedly  predisposing  cause. 
Examination  of  the  thigh  bones  of  old  people,  those  that  have  been 
broken  and  those  that  have  not,  bears  out  this  indication,  for  it  shows 
all  the  parts  of  the  bone  much  rarefied,  with  thinning  of  the  cortical 
shell  and  enlargement  of  the  meshes  of  the  spongy  tissue. 

Another  reason  for  the  greater  frequency  of  these  fractures  in  the 
old  has  been  sought  in  a  change  alleged  to  take  place  in  the  angle  at 
which  the  neck  joins  the  shaft.  It  has  been  asserted  that  as  the  indi- 
vidual grows  older  this  angle  approaches  a  right  angle,  a  position  that 
would  favor  fracture,  but  examination  has  proved  this  not  to  be  the 
rule. 

Other  points  in  the  connection  between  the  neck  and  the  shaft  require 
mention  because  of  their  influence  in  the  production  of  the  fracture  and 
m  the  character  of  the  displacement.  The  antero-posterior  diameter 
of  the  neck  is  much  smaller  than  that  of  the  shaft,  and  the  two  are  so 
joined  that  a  large  part  of  the  great  trochanter  lies  behind  the  posterior 
wall  of  the  neck,  and,  as  shown  by  Prof.  Bigelow,^  it  is  traversed  in 
part  by  a  prolongation  of  the  posterior  wall  of  the  neck  (Fig.  239). 
This  prolongation  which  Bigelow  calls  the  true  neck  constitutes  a  ver- 
tical septum,  "a  thin  dense  plate  of  bone  continuous  with  the  back  of 
the  neck,  and  reinforcing  it,  plunging  beneath  the  intertrochanteric 
ridge  in  an  endeavor  to  reach  the  opposite  and  outer  side  of  the  shaft. 
At  its  lower  extremity  it  curves  a  little  forward  so  as  to  take  its  origin, 
when  on  a  level  with  the  lesser  trochanter,  from  the  centre  instead  of 
the  back  of  the  cylindrical  cavity."  The  posterior  part  of  the  tro- 
chanter is  therefore  only  an  apophysis  attached  to  the  shaft  for  the 
insertion  of  the  rotator  muscles,  and  the  mechanical  fimction  of  the 
shaft  and  neck  with  reference  to  the  resistance  to  strain  is  practically 
independent  of  it.  The  rarefying  senile  change  affects  this  septum  and 
may  remove  it  so  completely  that  it  cannot  l)e  distinguished  from  the 
surrounding  cancellous  tissue. 

The  capsule  is  usually  attached  to  the  femur  in  front  along  the  spiral 

1  Bigelow:  The  Hip,  p.  121. 


FRACTURES  OF   THE  FEMUR. 


363 


Fig.  239. 


line,  above  to  the  neck  a  little  short  of  its  junction  with  the  trochanter, 
behind  to  the  neck  itself  about  half  an  inch  from  the  intertrochanteric 
line,  and  below  to  the  upper  part  of  the 
lesser  trochanter.  In  front  and  below, 
therefore,  the  neck  lies  entirely  within 
the  ca])sule,  while  above  and  behind  its 
outer  third  or  fourth  part  is  external  to  it. 
These  limits  vary  somewhat  in  dijBPerent 
individuals.  The  synovial  membrane  does 
not  follow  the  capsule  closely  to  its  inser- 
tion, but  it  is  reflected  early  from  it  to  the 
neck,  leaving  a  strip  of  the  latter  between 
the  points  where  it  joins  the  capsule  and 
the  synovial  membrane  which  although 
intracapsular  is  yet  extra-articular.  The 
periosteum  is  thick,  and  contains,  especially 
in  its  upper  portion,  numerous  bloodvessels 
which  enter  the  head  and  neck  by  the  large 
foramina  found  there.  Of  these  vessels, 
one  in  particular,  a  branch  of  the  internal 
circumflex  artery,  is  of  considerable  size, 
runs  along  the  upper  portion  of  the  neck 
and  enters  the  head.  Wilkinson  Kiug^ 
long  ago  called  attention  to  the  fact  that 
this  portion  of  the  periosteum  is  frequently 
left  untorn  in  fracture  of  the  narrow  part 
of  the  neck,  and  suggested  that  this  arte- 
rial branch  might  preserve  the  vitality  of 
the  head  of  the  bone  under  such  circum- 
stances. Later  observations  indicate  that 
the  vitality  is  preserved,  and  presumably 
by  thisageucy,  much  more  frequently  than  has  long  been  supposed. 

The  division  into  intracapsular  and  extracapsular  fractures,  so  long 
current  and  still  so  widely  used,  had  its  origin  in  important  pathological 
differences,  but  it  has  proved  unsatisfactory  and  misleading,  partly 
because  the  two  terms  do  not  properly  express  these  diflerences  and, 
consequently,  leave  a  large  group — the  "mixed"  fractures,  those  in 
which  the  line  of  fracture  lies  partly  within  and  partly  without  the 
capsule — to  be  classed  sometimes  with  one  and  sometimes  with  the 
other,  and  partly  because  the  associated  theory  that  repair  was  inqios- 
sible  after  intracapsular  fracture,  although  subsequently  abandoned  by 
its  author,  Sir  Astley  Cooper,  and  many  times  disproved,  has  clung  to 
it  in  many  minds  until  the  present  time.  The  breaking  away  from 
this  classification  which  has  appeared  in  so  many  of  the  systematic 
writings  of  the  last  thirty  years  is  largely  due  to  the  late  Professor 
Bigelow  who  suggested  the  terms /roc/ //re  at  the  narrow  part  of  the  neck 


Neck  of  femur.     (Bigelow.) 


1  King:  Guy's  Hospital  Reports,  1844,  p.  347. 


364  FRACTURES. 

and  fracture  at  the  base  of  the  neck.  These  have  the  disadvantage  of 
being  rather  cumbrous  and  of  unduly  limiting  the  seat  of  fracture  in 
the  former,  for  which,  therefore,  it  seems  to  me  advisable  to  substitute 
the  term  fracture  through  the  neck.  An  alternative  measure  recom- 
mended by  some  (most  recently  Sir  William  Stokes*),  of  fracture  of  the 
neck  for  the  former  and  at  the  base  of  the  neck  for  the  latter,  is  open  to 
the  objection  that  the  first  is  also  habitually  used  for  the  injury  as  a 
whole  and  is,  therefore,  liable  to  be  misunderstood  when  used  as  mean- 
ing either  more  or  less  than  was  intended.  Kocher's^  recently  proposed 
fractura  subcapitalis  for  the  first  finds  some  favor,  hwt  fractura  inter- 
trochanterica  and  fractura  pertrochanterica  for  the  latter  do  not  seem 
likely  to  be  acceptable. 

The  importance  of  the  distinction  in  prognosis  and  treatment  is  cer- 
tainly not  so  great  as  has  been  alleged,  nor  is  the  presence  or  absence 
of  so-called  impaction.  The  capital  point  in  prognosis — the  degree  of 
vitality  of  the  upper  fragment — apparently  depends  not  upon  impac- 
tion nor  upon  the  situation  of  the  fracture,  but  upon  the  preservation 
of  the  vascular  supply  furnished  by  the  vessels  which  approach  the  bone 
near  the  insertion  of  the  capsule  and  run  to  the  head  in  the  thick  peri- 
osteum of  the  neck.  In  fractures  at  the  base  of  the  neck  these  vessels 
are  not  much  injured,  and  in  fractures  at  the  narrow  part  of  the  neck 
the  continuity  of  the  periosteum  and  the  included  vessels  appears  to  be 
sufficiently  preserved  in  many,  perhaps  most,  cases  to  maintain  the 
vitality  of  the  fragment.  The  number  of  specimens  of  bony  union 
after  undoubted  fracture  at  the  narrow  part  of  the  neck  is  not  only 
large  enough  amply  to  demonstrate  the  possibility  of  such  repair,  but 
also,  in  comparison  with  those  of  failure  of  union  and  in  connection 
with  clinical  results,  to  indicate  that  snch  union  is  probably  common 
under  appropriate  treatment  and  in  the  absence  of  injudicious  move- 
ments at  first  which  may  destroy  the  connection  left  by  the  fracture. 
Moreover,  it  is  clinically  impossible  positively  to  distinguish  between 
many  of  these  fractures  at  the  narrow  part  of  the  neck  and  those  at 
the  base  in  which  there  is  little  or  no  injury  to  the  adjoining  part  of 
the  shaft  and  its  periosteum. 

It  therefore  seems  to  me  unwise  to  make  a  sharp  distinction  between 
the  two  forms  and  to  urge,  as  some  do,  that  fractures  of  the  narrow  part 
of  the  neck,  or  intracapsular,  should  be  deemed  from  the  first  inca- 
pable of  union  and  treated  accordingly.  I  think,  on  the  contrary,  that 
union  should  be  sought  in  all  cases  and  almost  always  by  the  same 
methods  and  that  the  diagnostic  differentiation  at  the  outset,  therefore, 
is  rarely  of  practical  importance  in  treatment,  although  affecting  prog- 
nosis. Although  the  distinction  must  be  preserved  in  the  description 
of  the  forms  of  fracture  (I  shall  use  the  names  fracture  through  the 
neck,  or  subcapital,  and,  fractures  at  the  base  of  the  iieck)  the  sections 
on  symptoms  and  treatment  will  treat  of  them  jointly. 

In  order  to  get  an  indication  of  the  relative  frequency  of  the  two 
forms  I  examined  the  .T-ray  plates  of  33  successive  patients  at  the  New 

1  Stokes:   British  Medical  Journal,  October  12,  1895. 

2  Kocher :  Praktisch   wichtiger  Frakturformen,    1896. 


FkACTURES  OF  THE  FB'MUR.  365 

York  Hospital ;  27  were  at  the  base  of  the  neck  and  6  at  various  points 
in  the  neck;  one  of  the  latter  was  quite  close  to  the  base.  An  examina- 
tion of  such  few  plates  at  Bellevue  Hospital  as  were  clear  enough  to 
give  positive  information  gave  21  at  the  base  and  S  at  the  neck. 

Of  38  cases  admitted  to  the  New  York  Hospital  between  January, 
1911  and  August,  1916,  27  were  at  the  base  and  11  in  the  narrow 
part  of  the  neck  including  one  separation  of  the  epiphysis  in  a  child  of 
four  years. 

Causes. 

An  important  predisposing  cause  has  beeu  mentioned,  the  senile 
rarefaction  which  begins  usually  after  the  fiftieth  year  and  is  more 
marked  in  females  than  in  males. 

The  common  cause  in  the  old  is  a,  fall  to  the  ground  while  walking ; 
occasionally  a  stumble  or  a  misstep  with  an  effort  to  avoid  a  fall,  or  the 
jar  occasioned  by  stepping  down  to  a  slightly  lower  level  than  was 
anticipated.^  In  the  young  the  cause  is  also  usually  moderate  violence, 
but  in  robijt  adults  it  is  usually  much  greater  violence,  as  in  a  fall 
from  a  height,  but  reports  of  cases  are  accumulating  which  indicate  that 
a  perhaps  notable  proportion  of  injuries  caused  by  moderate  violence 
and  deemed  sprains  or  contusions  of  the  hip  are  fractures,  incomplete 
or  without  separation. 

It  is  probable  that  the  strain  exerted  through  the  ligaments  in  ex- 
treme positions  of  the  limb  is  a  more  frequent  cause  of  fracture  than 
is  generally  supposed,  and  that  the  fall  is  sometimes  the  consequence 
rather  than  the  cause.  A  number  of  cases  are  on  record  in  which  the 
bone  has  been  broken  in  this  manner,  and  by  efforts  so  slight  in  some 
of  them  that  they  might  easily  have  been  overlooked  if  a  fall  had  been 
associated  with  them,  and  experiment  upon  the  cadaver  confirms  the 
opinion.  The  efforts  which  have  been  made  to  explain  different  varie- 
ties of  fracture  by  differences  in  the  direction  of  the  blow  or  in  the 
point  at  which  it  has  been  received  have  not  been  satisfactory  either  as 
a  demonstration  or  as  an  aid  in  diagnosis.  Few  patients  are  able  to 
tell  exactly  how  they  have  fallen,  and  even  if  they  could  do  so  there 
would  still  be  enough  uncertainty  concerning  the  extent  to  which  the 
position  of  the  limb  had  intervened  to  vitiate  the  conclusions  that 
might  otherwise  be  drawn  from  the  circumstances  of  the  fall.  On 
the  cadaver  the  bone  can  be  broken  at  the  narrow  part  of  the 
neck  by  a  blow  on  its  head,  or  on  the  knee  when  the  limb  is 
somewhat  abducted,  and  at  the  base  of  the  neck  by  a  blow  upon 
the  trochanter,  if  the  cadaver  is  that  of  an  old  person  ;  and  it  is 
comparatively  easy  to  break  the  bone  in  the  old,  either  at  the  base 
or  at  the  narrow  part  of  the  neck,  by  abduction,  adduction,  or 
rotation.  In  some  of  the  fractures  produced  by  strain  through  the 
ilio-femoral  ligament  (by  hyperextension  and  abduction)  the  break 
takes  place  outside  the   attachment  of  the  ligament  along   the   spiral 

1  For  illustrative  cases  of  fracture  by  slight  causes  and  of  experimental  fracture  see 
previous  editions  and  Cooper,  loc.  cit.,  pp.  15.")  and  157;  Earle,  Practical  Obs.  on  Surf;.. 
1822,  p.  20;  Malgaigne,  loc.  cit.,  vol.  i.  p.  666;  Linhart,  Deutscbe  Gesell.schaft  fur  t'hir., 
1875*;  Ried'inger,  Ccntralblatt,  fiir  Cbir.,  1875,  p  817;  Stetter,  Idem.  1877,  p.  561. 


366 


FRACTURES. 


line  and  the  ligament  remains  attached  to  the  upper  fragment.  In 
others  with  apparently  the  same  mode  of  production  the  fracture  is 
through  the  narrow  part  of  the  neck.  ^  .  ^  ^ 

Muscular  action  may  be  a  cause  by  producing  a  forced  position  of  the 
limb  in  which  the  capsule,  and  especially  the  Y-ligament,  is  put  upon 
the  stretch,  the  mechanism  then  being  the  same  as  when  the  corre- 
sponding position  is  given  by  an  external  force. 


Pathology. 

The  line  of  fracture  may  lie  at  any  point  between  the  junction 
of  the  head  and  neck  and  the  base  of  the  neck,  and  in  the  latter 
case  it  may  be  associated  with  more  or  less  splitting  of  the  trochanter 
and  arljoinina:  shaft,  or  it  may  pass  (rarely)  from  the  lower  part  of 


Fig.  240. 


Fig.  241. 


Fracture  through  the  neck  of  the  femur. 
capitalis.)    (Kochee.) 


{F.  sub- 


So-called  "incomplete"  fracture  of  the 
neck  of  the  femur.    (Konig.) 


the  junction  of  the  neck  and  shaft  transversely  to  the  outer  side. 
Fractures  at  a  somewhat  lower  level,  below  the  trochanter  minor,  will 
be  considered  among  fractures  of  the  shaft.  There  are,  therefore,  to  be 
considered  here  fractures  through  the  neck,  fractures  at  the  base  of  the 
neck  with  or  without  splitting  of  the  trochanter,  separation  of  the 
epiphysis,  and  fracture  through  the  trochanter. 

(a)  Fractures  Through  the  Neck.  (Intracapsular  fracture,  subcapital 
fracture.)  The  frequency  of  these  fractures  has  been  thought  to  in- 
crease with  advancing  age  after  sixty  years,  but  the  facts  upon  which 
the  opinion  rests  are  mainly  clinical  and,  therefore,  not  entirely  trust- 
worthy.   I  am  convinced,  by  clinical  evidence  as  well  as  bv  the  statis- 


FRACTURES  OF  THE  FEMUR. 


3G< 


Fracture  through  the  neck.    Eighty-two  years. 
Rear  view. 


tics  given  on  the  preceding  page  that,  except  perhaps  in  the  young,  this 
form  is  mucli  less  frequent  than  fracture  at  the  l)ase. 

The  line  of  fracture  may  be 
transverse,  oblique,  or  irregular ;  Fig.  242. 

it  may  lie  close  to  the  head  or 
at  some  distance  from  it,  or  may 
(rarely)  pass  slightly  into  the 
head  itself.  In  a  few  old  speci- 
mens the  appearance  suggests 
that  the  line  of  fracture  was  in- 
complete on  one  side,  but  as  the 
head  in  such  cases  shows  a  well- 
marked  angular  displacement  it 
is  prol)able  that  the  fracture  was 
complete  with  bending  but  no 
other  displacement  at  the  ap- 
parently continuous  portion  and 
crushing  elsewhere.  The  surface 
of  fracture  is  frequently  irreg- 
ular, but  .sometimes  uniform  and 
sometimes  smooth  or  irregular 
on  the  side  of  the  head,  while  the 
neck  on  the  other  side  is  crushed 
or  comminuted. 

Angular  deviation  at  the  fracture  is  the  rule,  the  apex  of  the  angle 
being  usually  directed  forward  and  upward,  and  is  habitually  effected 

by  crushing  of  the  bone  or  by 
Fig.  243.  penetration  of  one  fragment  into 

the  other.  This  penetration  or 
impaction  is  rarely  more  than  a 
simple  interlocking  of  the  irreg- 
ularities of  the  surface,  although 
Bigelow  ^  reported  one  in  which 
considerable  force  was  required 
to  separate  the  fragments  ;  pos- 
sibly the  fixation  was  due  to  in- 
completeness of  the  primary  sep- 
aration at  some  point  on  the 
periphery,  as  in  the  so-called 
"  incomplete "  fractures  (Fig. 
241). 

The  periosteum  of  the  neck 
appears  usually  to  remain  untorn 
ovor  a  portion  of  the  perijihcry, 
and  may  even  be  complete,  as  in 
ca.ses  reported  by  Mayor  ^  and 
Stanley.^  In  one  of  my  speci- 
mens the  nntorn  portion  is  nearly 
an  inch  wide  and  is  situated  at  the  lower  and  posterior  portion  of  the 


Fracture  through  the  neck.    EigLty-two  years. 
Front  view.    (Army  Med.  Museum.) 


'  Bigelow:  Loc.  cit.,  p.  1.31.  ^  Mayor:  Gazette  Medicale.  1834,  p.  612. 

'Stanley:  Medico-Chirurgical  Transactions.  1825,  vol.  xiii.  d.  511. 


368 


FRACTURES. 


Fig.  24:5. 


neck;  in  another  it  was  broadly  preserved  in  three  bands;  in  other 
reported  cases  it  has  been  behind,  behind  and  above,  and  above  and  in 
front.  If  the  primary  displacement  is 
great,  or  if  it  is  increased  by  an  attempt 
to  bear  the  weight  npon  the  limb,  the 
rupture  raav  be  or  may  become  complete 
and  the  fragments  may  be  widely  sep- 
arated,    both     of    which    circumstances 

Fig.  244. 


Fracture  through  the  neck;  died  in  six  weeks.    Show-       Fracture  through  the  neck  in  a  boy 
ing  absorption.  eight  years  old.    (Bolton.) 

would  seriously  aflPect  the  prognosis ;  under  similar  circumstances  the 
capsule  may  be  torn. 

(6)  Separation  of  the  epiphysis  has  been  demonstrated  by  specimen 


Fig.  246. 


Separation  of  the  epiphysis;  old.    (Kocher.) 


in  a  few  cases  and  suspected  in  a  number  in  which  fracture  of  the  neck 
has  occurred  in  the  young,  but  there  is  reason  to  believe  that  it  is  rarer 


PRACTUBES  OP  THE  FEMUR.  369 

even  than  fracture  at  the  corresponding  age.  The  conjugal  cartilage 
immediately  adjoins  the  head,  and  bony  union  takes  place  between  the 
seventeenth  and  twenty-first  years.  The  first  case  verified  by  direct 
examination  was  reported  by  Bousseau.^  The  patient  was  fifteen  years 
old,  and  was  run  over  by  a  wagon.  The  symptoms  were  shortening, 
eversion,  and  inability  to  move  the  limb.  Tlie  patient  died  in  a  few 
hours.  The  separation  was  complete  along  the  epiphyseal  line,  and 
the  head  was  attached  to  the  neck  only  by  a  strip  of  periosteum 
two  millimetres  wide.  The  periosteum  was  stripped  up  on  the 
inner  and  lower  part  of  the  neck,  and  the  capsule  was  torn  at  its 
inner  portion. 

Kocher^  reports  two.  The  first  is  that  of  a  gii-1  sixteen  years  old, 
who  fell  while  walking  and  struck  upon  her  right  trochanter.  On  the 
theory  that  if  the  injury,  as  supposed,  was  a  fracture  througli  the  neck 
(or  separation  of  the  epiphysis)  repair  was  impossible,  an  operation  was 
done  three  weeks  later  for  the  removal  of  the  ujjper  fragment.  A 
fracture,  hidden  by  the  untorn  periosteum,  was  found  along  the  epiphy- 
seal line,  with  penetration  of  the  posterior  part  of  the  neck  into  the 
head  ;  the  latter  was  removed  ;  recovery  with  anchylosis. 

The  second  case  was  that  of  a  girl  who,  when  ten  years  old,  fell 
from  a  height ;  she  rose  and  walked  a  short  distance,  was  then  unable 
to  use  the  limb  because  of  pain,  and  was  taken  to  a  hospital.  After 
apparent  recovery  she  walked  with  a  limp  which  increased  as  time 
passed.  Four  years  after  the  accident  Kocher  found  shortening  of 
three  centimetres  outward  rotation,  and  marked  diminution,  active 
and  passive,  of  motion  in  the  hip-joint.  The  condition  found  at  the 
operation  is  shown  in  Fig.  246;  the  head  was  so  tightly  fixed  in  the 
acetabulum  that  it  was  removed  with  difficulty ;  the  neck  was  bent 
sharply  downward  with  an  irregular,  knobbed  end,  covered  with  fibro- 
cartilage ;  the  end  was  placed  in  the  acetabulum  and  the  limb  fixed 
in  abduction  and  inward  rotation.  The  history  ends  with  the  recovery 
from  the  operation. 

Poland^  reports  a  personal  case  verified  by  operation  and  quotes 
two  others,  and  Whitman  *  reports  one  in  which  the  injury  was 
caused  by  forcible  abduction  of  the  thigh  in  a  lad  sixteen  years  old, 
the  diagnosis  being  confirmed  by  a  skiagram  taken  three  weeks  after 
the  accident.  He  thinks  the  separation  is  often  only  partial,  the  symp- 
toms at  first  being  only  a  slight  limp  with  some  stiffness  and  pain,  and 
later,  after  some  slight  violence,  those  of  fracture.  In  two  cases  he  cor- 
rected the  displacement  through  an  anterior  incision.  Ramstedt^  thinks 
that  nearly  all  injuries  of  the  neck  of  the  femur  in  patients  less  than 
eighteen  years  old  are  separations  of  the  epiphysis  and  that  coxa  vara 
is  a  frequent  result. 

'  Bousseau  :  Bulletins  de  la  Societe  Anatomique,  1867,  p.  283. 
2  Kocher:  Praktisch  wicbtlger  Frakturfornien,  1896,  pi).  23H  and  243. 
'  Poland  :   "Traumatic  Separation  of  the  Epiphyses,"  p.  628. 

*  Whitman  :  Annals  of  Surgery,  February,  1900,  \^.  1.51.  See  also  Med.  News,  Septem- 
ber 24,  1904. 

'Raiustedt ;  Arch.  fiir.  klin.  Chir.,  vol.  Ixi.  part  3. 


370 


FRACTURES. 


Since  the  use  of  the  2;-rays  has  become  general,  observations  of  this 
injury  have  accumulated,  but  without  entirely  removing  the  possible 
confusion  of  it  with  fracture  of  the  neck  close  to  the  head.  Several 
authors  believe  it  to  be  the  cause  of  most,  perhaps  all,  of  the  observed 
cases  of  coxa  vara.^  It  certainly  is  frequent  enough  to  make  it  im- 
portant to  bear  its  possible  presence  in  mind  in  the  examination  of 
injuries  of  the  region  in  the  young,  if  they  are  accompanied  by  pain, 
more  or  less  disability,  and   limitation  of  motion,  especially  in  abduc- 

FiG.  247. 


Impacted  fracture  at  the  base  of  tlie  cervix  femoris,    with  bending  of  the  head  backward, 

(BiGELOW.) 

tion  and  inward  rotation.  Diminished  adduction,  coxa  valga,  though 
rare,  is  occasionally  seen.  Notwithstanding  the  lack  of  control  of  the 
proximal  fragment,  forcible  correction  by  abduction  and  inward  rota- 
tion (Sprengel,  Zttblattfdr  Chir.,  1909,  p.  1745)  has  yielded  some  sat- 
isfactory results. 

(c)  Fractures  at  the  Base  of  the  Neck.  (Extracapsular  and  "mixed" 
fractures).  The  line  of  fracture  follows  ordinarily  the  junction  of  the 
neck  and  shaft  quite  closely — that  is,  it  coincides  with  the  spiral  line  in 
front  and  the  intertrochanteric  line  behind  as  they  pass  between  the 
great  and  lesser  trochanters.     It  may  extend  downward  and  detach  the 

» Fettig:  Arch,  fiir  klin.  Chir.,  1909,  vol.  Ixxxix.  p.  912. 


FRACTURES  OF   THE  FEMUR. 


371 


Fig.  248. 


Fig.  249. 


Impacted  fracture  of  the  neck  of  the  femur 
without  splintering.    Vertical  section. 


Repair  after  fracture  of  the  neck  of  the  femur, 

(LOSSEN.) 


lesser  trochanter  from  the  shaft,  leaving  it  attached  to  the  neck,  or  go 
even  lower  and  separate  a  part  of  the  shaft.     At  its  upper  part  it  may 


Fig.  250. 


Fig.  251. 


Comminuted  fracture  of  the  neck  of  the  femur. 
Anterior  aspect. 


Fracture  of  the  neck  of  the  femur  with 
splitting  of  the  great  trochanter. 


deflect  to  either  side,  crossing  the  outer  part  of  the  neck  or  traversing 
the  great  trochanter,  in  the  latter  case  passing  quite  ))eyond  the  limits 
of  the  neck. 


372 


FRACTURES. 


In  the  majority  of  cases  other  lines  of  fracture  traverse  one  or  both 
trochanters,  splitting  off  one  or  two  pieces,  usually  from  the  posterior 
surface  of  the  great  trochanter,  or  comminuting  it  completely.  Mal- 
gaigne  thought  that  simple  fracture,  division  into  only  two  fragments, 
was  exceedingly  rare ;  the  only  case  of  which  he  knew,  excluding  two 


Fig.  252. 


Fig.  253. 


Fig.  254. 


Fig.  255. 


X-ray  tracings  of  fracture  of  the  neck  of  the  femur. 


in  which  the  fracture  crossed  the  trochanter  horizontally,  was  one 
described  by  R.  W.  Smith, ^  and,  as  even  in  this  two  fragments  are 
broken  off  the  trochanter  behind,  it  is  evident  that  he  believed  consid- 
erable comminution  to  be  the  rule.  Hamilton  refers  to  two  similar 
specimens,  one  in  Dr.  ISIutter's,  the  other  in  Dr.  Xeill's  collection;  in 
one  of  my  own  specimens  there  was  no  splintering,  and  in  another  the 

1  R.  W.  Smith:  Loc.   cit.,   Case  34. 


FRACTURES   OF  THE  FEMUR. 


373 


fracture  was  almost  identical  with  the  one  quoted  by  Malgaigne  from 
Smith. 

The  common  fracture  is  that  in  which  the  neck  is  bent  backward 
with  crushing  of  the  posterior  part  or  penetration  of  the  neck 
into  the  trochanter.  Prof.  Bigelow  ^  directed  especial  attention  to  this 
bending  backward  and  impaction  (Fig.  247)  as  the  important  features 
of  the  most  common  form  of  fracture  in  tliis  region,  the  symptoms  of 
which  are  pain  and  tenderness,  disability,  shortening  and  eversion,  how- 
ever slight,  absence  of  crepitus,  and  rotation  of  the  trochanter  about 
the  head  of  the  bone  as  a  centre,  and  he  described  the  displacement  as 
a  rotation  of  the  head  and  neck  l^ackward  and  downward  upon  the 

Imu.  2r,r,. 


Comminuted  fracture  at  the  base  of  the  neck  of  the  femur. 

portion  of  the  anterior  wall  corresponding  to  the  spiral  line  uniting  the 
trochanters  as  upon  a  hinge.  This  displacement  accounts  for  the  ever- 
sion and  slight  shortening. 

A  certain  amount  of  misapprehension  has  resulted  from  the  use  of 
the  word  impaction.  Impaction,  in  the  sense  of  penetration  and  fixa- 
tion, is,  I  think,  uncommon  ;  while  crushing,  with  or  without  penetra- 
tion or  much  splitting  of  the  trochanter,  is  the  rule.  The  penetration 
or  crushing  may  be  limited  to  the  posterior  part  (this,  as  has  been  said, 
is  the  most  common  condition),  or  the  neck  may  tnrn  upon  its  upper 
portion,  making  that  the  hinge,  and  sink  its  anterior,  posterior,  and 
lower  walls  into  the  substance  of  the  trochanter,  or  the  neck  may  be 

1  Bigelow:  The  Hip,  p.  118,  and  Boston  Medical  and  Surgical  .Journal,  187.'),  vol.  xcii. 
pp.  1,  29. 


374 


FRACTURES. 


driven    bodily  into  the  trochanter  without  much  change  of  direction, 
and  may  even  penetrate  to  the  opposite  wall.     In  exceptional    cases 

the  lower  fragment  may  penetrate 
Fig.  257.  the  upper  one. 

The  splitting  of  the  trochanter 
may  be  limited  to  one  or  two  pieces 
broken  off  its  posterior  border  (Fig. 
251),  or  it  may  be  very  general  (Fig. 
256).  The  extent  of  the  splitting 
seems  to  be  independent  of  the  force 
that  caused  the  fracture,  extensive 
comminution  being  sometimes  pro- 
duced by  a  simple  fall  while  walk- 
ing, as  in  Fig.  250,  which  is  drawn 
from  one  of  my  own  specimens.  Oc- 
casionally the  unbroken  trochanter 
may  be  wholly  detached  from  both 
neck  and  shaft  (Fig.  257). 

In  a  few  cases  the  angular  dis- 
placement of  the  neck  has  been  in 
the  opposite  direction,  so  that  the  limb  has  been  rotated  in-sATird  instead 
of  outward.     R.  W.  Smith  ^  describes  one  such  specimen,  and  Bigelow  ^ 


Total  separation  of  great  trochanter. 

(Frangenheiji.) 


Fig.  258. 


Fig.  259. 


Fracture  of  the  neck  of  the  femur  in 
abduction.    (Kochee.) 


Fracture  of  the  neck  of  the  femur  in  adduction. 

(KOCHER.) 


another.     In  a  number  of  cases  inversion  has  existed  when  the  frag- 
ments were  not  interlocked. 


1  B.  W.  Smith  :  Loc.  cit.,  p.  128. 


*  Bigelow:  Loc.  cit.,  p.  128. 


FRACTURES  OF  THE  FEMUR. 


375 


The  angular  displacement  of  the  neck  and  the  form  of  the  fracture 
appear  to  be  connected  with  the  mode  of  production  of  the  fracture 
and  the  attitude  of  the  limb  at  the  moment  of  fracture  ;  thus,  if  the 
limb  is  extended  and  rotated  outward  or  abducted  the  anterior  por- 
tion of  the  capsule  is  tense  and  tlie  posterior  portion  of  the  neck  is 
driven  into  the  trochanter  (Fig.  258);  if  the  limb  is  strongly  adducted 
the  deep  penetration  is  found  especially  at  the  inferior  portion  of  the 
neck  (Fig.  259). 


Fig.  260. 


Fig.  261. 


Pure  intracapsular  fracture  of  the  neck  of  the 
femur.    Bony  union.    (Guelt.) 


Oblique  section  of  the  specimen  shown 
in  Fig.  246.    (Gurlt.) 


The  capsule  is  sometimes  torn  so  that  the  cavity  of  the  joint  is 
opened  ;  the  laceration  of  the  periosteum  and  adjoining  soft  parts  varies 
with  the  extent  of  the  comminution  and  crushing. 


Repair. 

The  question  of  the  extent  to  which  repair  is  possible  or  probable 
after  fracture  through  the  neck  is  important  because  of  its  bearing 
upon  treatment.  If  reunion  is  possible  an  effort  to  obtain  it  should 
be  made,  in  the  absence  of  controlling  contraindications ;  if  it  is  im- 
possible or  even  improbable,  treatment  must  be  directed  to  obtaining 
the  best  functional  result  compatible  with  such  failure. 

That  repair  is  possible  is  abundantly  proved  by  specimens,  even  if 
we  disregard  those  in  which  any  question  can  be  raised  as  to  the  charac- 
ter of  the  injury  or  the  exact  situation  of  the  fracture.  Such  illustrative 
specimens  are  those  of  Stanley,^  Swan,^  Gurlt ^  (Figs.  260  and  201), 
Brulatour,*    Gushing,'^  Humphry,^  Raven,''  and  Kocher^  (Fig.    202).^ 

1  Stanley:  Medico-Chirurgical  Transactions,  1838,  vol.  xviii.  p.  2'-)i). 

2  Swan  :  Quoted  by  R.  W.  Smith,  Fractures  in  the  Vicinity  of  Joints,  p.  .59. 
•^  Gurlt:  Knochenbriichen,  vol.  i.  p.  308. 

♦  Brulatour:  Medico-Chirurgical  Transactions,  1825,  vol.  xiii.  p.  rA'.l. 
5  Gushing  :  Quoted  by  Bigclow,  The  Hip,  p.  133.      "  Humphry  :  Lancet,  August  2,  ls!)0. 
'  Raven:  Ibid.,  1887.  8  Kocher:'Loc.  cit.,  p.  200. 

»  For  other  cases  and  details  the  reader  is  referred  to  the  first  edition  and  the  bibliog- 
raphy in  it,  page  499. 

27 


376 


FRACTURES. 


Fig.  262. 


Thej  include  patients  of  ages  varying  from    eighteen    to    eighty-one 
years. 

Other  specimens  show  close  fibrous  union  (Figs.  263  and  264) ;  and 
others  in  which  no  form  of  union  had  taken  place  show  eburnation  of 

the  head  and  other  changes  which 
demonstrate  the  preservation  of  its 
vitality.  After  fibrous  union  or 
failure  of  union  the  capsule  usually 
thickens  and  sometimes  becomes 
closely  adherent  to  the  periosteum 
lining  the  neck,  thus  obliterating 
all  the  outer  portion  of  the  original 
cavity  of  the  joint.  This  was  the 
condition  in  two  cases  reported  by 
Colles/  and  there  was  actually  a 
false  joint  between  the  fragments, 
the  surface  of  the  lower  one  being 
hollowed  out  to  receive  the  upper. 
The  process  of  repair  has  been 
minutely  studied  by  Frangenheim.^ 
He  found  that  the  periosteum  of  the 
neck  forms  little  or  no  callus,  so  that 
union  after  subcapital  fracture  must 
be  eifected,  if  at  all,  by  the  spongy 
tissue.  Fibrous  union  may  be  close 
and  firm.  Absorption  of  the  neck 
may  take  place  very  promptly ;  he 
thought  it  occurred  only  after  sub- 
capital fracture.  Occasionally  the 
opposing  surfaces  of  head  and  neck 
become  eburnated  and  a  nearthrosis 
is  formed.  He  quotes  with  approval  Gurlt's  statement  that  fracture  of 
the  neck  of  the  femur  is  the  slowest  of  all  fractures  to  heal,  and  gives 
a  case  of  deeply  impacted  fracture  at  the  base,  in  which  union  after 
eight  and  one-half  months  was  still  fibrous,  although  so  firm  that  it 
was  thought  to  be  bony  before  the  specimen  had  been  sawn. 

Some  specimens  of  failure  of  union  show  entire  disappearance  of  the 
neck,  the  head  remaining  in  the  acetabulum  and  presenting  a  smooth 
uniform  surface  ;  there  is  a  similar  smooth  surface  on  the  mesial  aspect 
of  the  shaft  at  the  place  corresponding  to  the  base  of  the  neck  (Fig. 
265).  The  situation  of  the  fracture  in  such  cases  cannot  be  positively 
known  ;  the  neck  has  disappeared  by  crushing  and  rarefaction,  and  this 
presumably  can  happen  after  either  form  of  fracture. 

Some  specimens  with  union  show  an  almost  equal  absence  of  the 
neck  ;  in  some,  as  shown  in  Fig.  249,  the  neck  still  exists,  but  has 
been  driven  into  the  trochanter ;  in  others  it  has  disappeared  in  great 
part,  pi'esuraably  by  crushing  and  rarefactive  osteitis,  and  it  is  difficult 
or  impossible  exactly  to  determine  the  primary  position  of  the  fracture. 

'Colles:  Dublin  Hospital  Eeports,  vol.  ii.  p.  334. 

'Fraugenheim  :  Deutsche  Zeitschrift  fiir  Chir.,  1906,  vol.  83,  p.  401. 


Bony  union  after  fracture  through  the  neck, 
{F.  subcapitalis.)    (Kochek.) 


FRACTURES  OF   THE  FEMUR. 


377 


These  latter  specimens  are  of  special  interest  because  they  have  been 
used  to  support  the  theory  that  interstitial  absorption  of  the  neck  may 


Fig.  263. 


Fig.  264. 


Fracture  within  the  capsule ;  fibrous  union. 
(Smith.) 


Fracture  within  the  capsule.   Close  fibrous  union. 


Fig.  265. 


be  caused  by  a  contusion,  without  fracture,  :uid  that  thus  may  be  grad- 
ually produced  a  deformity 
clinically  identical  with  that 
following  fracture.  I  have 
given  elsewhere  ^  reasons  for 
deeming  this  theory  incorrect 
and  for  believing  all  such  al- 
leged cases  to  be  those  of  un- 
recognized fracture. 

Other  specimens,  and  they 
are  numerous,  show  an  abun- 
dant production  all  about  the 
trochanter  and  upper  end  of 
the  shaft.  In  part  this  en- 
largement is  due  to  splitting 
and  displacement  of  the  frag- 
ments, but  the  greater  part  of 
it  is  new  bone  produced  sub- 
periosteally,  or,  more  prob- 
ably, by  ossification  of  the 
attached  fibrous  and  tendi- 
nous tissues.  This  is  espe- 
cially connnon  at  the  back, 
along  the  intertrochanteric 
line.  Sometimes  these  masses 
so  embrace    the  end    <jf   tlie 

ununited  upper  fragment  (neck)  that  the  patient  can  walk  well  without 
the  aid  of  cane  or  crutch  (Fig.  266). 

1  Stimson  :   "  Doubtful  Fractures  of  the  Neck  of  the  Femur  and  their  Identity  with  an 
Alleged  Form  of  Arthritis  Deformans,"  New  York  Medical  Journal,  April  14,  IbSb. 


Fracture  willi  ab.sorptiim  (if  the  neck. 


378  FRACTURES. 

The  cavity  of  the  joint  is  sometimes  diminished  by  an  adhesive  syno- 
vitis which,  aided  by  peri-articular  thickening  and  retraction  and  by  the 
above-mentioned  osteophytic  growths,  greatly  restricts  its  mobility. 

Occasionally  the  limb,  after  either  form  of  fracture,  remains  useless, 
and  much  pain  is  felt,  especially  if  union  has  failed  ;  and  there  are  a 
few  recorded  cases  in  which  suppuration  has  occurred  within  or  without 
the  joint. 

The  degree  of  probability  of  bony  union  after  fracture  through  the 
neck  could  be  determined  only  by  the  statistics  of  a  series  of  continuous 

Fig.  266. 


Fracture  of  the  base  of  the  neck.    Exuberant  caUus  and  interlocking  of  the  fragments  that  per- 
mitted fair  use  of  the  limb,  notwithstanding  failure  of  union. 

cases.  The  collation  of  reported  cases  is  not  sufficient  because  it  is 
certain  that  the  proportion  of  failures  of  union  therein  would  be  dis- 
proportionatelv  large;  the  examination  post  mortem  of  the  part  is  more 
likely  to  be  made  if  the  patient  remains  disabled  until  death  than  if 
he  has  regained  use  of  the  limb.  Most  of  the  specimens  we  possess 
of  bony  union  have  been  obtained  from  patients  who  died  from  some 
intercurrent  cause  within  a  comparatively  short  time  after  the  accident, 
while  its  memory  was  still  fresh.  The  information  now  accumulating 
by  the  aid  of  the  .r-rays  will  doubtless  aid  to  solve  these  questions. 

The  facts  in  oiu"  possession  are:  (1)  that  bony  or  close  fibrous  union 
dter  fracture  through  the  neck  is  possible;  (2)  that  the  preservation  of 
enough  of  the  periosteum  of  the  neck  to  make  a  vigorous  vitality  of  the 
head  probable  is  probably  common;  and  (3)  that  the  primary  displace- 
ment usually  does  not  separate  the  fractured  sm-faces,  so  that  if  it  is 
not  increased  by  early  attempts  to  use  the  limb  or,  more  rarely,  by  the 
action  of  the  muscles  in  the  absence  of  proper  retention,  the  con- 
ditions for  reunion  are  favorable.     We  also  know  that  fair  usefulness 


FRACTURES  OF  THE  FEMUR. 
Fig.  267. 


379 


Fracture  of  the  neck;  heafed.      (LL  S.  Army  Med.  Museum.) 


of  the  limb,  even  after  union  has  failed,  is  possible;  and  it  has  not  been 
proved  that  this  usefulness  is  greater  or  more  probable  if  the  attempt  to 
secure  union  has  not  been  made. 

If  union  takes  place  with   a  Fig.  268. 

marked  reduction  of  the  angle 
between  the  neck  and  the  shaft, 
coxa  vara,  there  will  be  not  only 
shortening  but  also  diminution 
of  abduction  of  the  joint;  and 
in  any  case  the  change  in  the 
length  of  the  neck  and  in  its 
angle,  the  exuberant  callus  in 
fractures  at  the  base  of  the  neck, 
and  the  arthritis  and  retraction 
of  the  periarticular  tissues  occa- 
sioned by  the  trauma  ensure,  ex- 
cept perhaps  in  the  young,  a 
definite  and  often  considerable 
diminution  of  the  range  of  motion 
in  the  joint. 

It  is  also  very  important  to  re- 
member that  long  after  union  has 
apparently  taken  place,  as  indica- 
ted by  ability  to  move  the  limb 


.jjM 


Marked  coxa  vara  after  fractur.'.      Ili-tc,r\-  u 
known.     (U.  S.  Army  Med.  Mubeum.; 


380  FRACTURES. 

quite  freely  and  painlessly,  it  can  be  abruptly  destroyed  by  refracture  or 
gradually  changed  with  marked  increase  of  the  shortening  by  premature 
use  of  the  limb  in  walking.  Several  months — four  to  six  in  most  cases — 
are  needed  for  full  consolidation. 

Symptoms  and  Diagnosis. 

The  symptoms  of  the  fracture  and  the  signs  upon  which  the  diag- 
nosis must  be  made  include  not  only  the  usual  objective  and  subjective 
symptoms  of  fracture  but  also  the  history  of  the  case,  the  nature  of 
the  violence,  and  especially  its  slight  degree,  which  so  often  ciiar- 
acterizes  this  injury. 

Interference  with  Function.  As  a  rule  the  patient  is  unable  to  use  the 
limb,  and  he  is  not  merely  unable  to  bear  his  weight  upon  it,  but  he 
cannot  even  move  it  in  bed.  Exceptions  to  this  have  been  already 
mentioned,  and  it  is  not  particularly  uncommon  to  see  patients  who, 
while  lying  on  the  back,  can  slowly  flex  the  thigh  upon  the  pelvis 
either  by  its  muscles  alone  or  with  the  aid  of  the  hands,  but  they  can- 
not raise  the  foot  from  the  bed,  the  knee  bends  at  the  same  time  and 
the  foot  is  drawn  up  toward  the  body.  Most  authors  have  mentioned 
cases  in  which  the  patients  have  walked  for  longer  or  shorter  distances 
immediately  after  the  injury,  and  in  which  the  existence  of  a  fracture 
has  subsequently  become  very  clear.  This  is  very  exceptional,  and  it  is 
sufficient  to  bear  the  possibility  in  mind  to  avoid  the  error  of  inferring 
that  a  fracture  cannot  be  present  because  the  patient  is  or  has  been  able 
to  use  the  limb.  Frangenheim  (loc.  cit.,  p.  449)  reports  one  fifty- 
seven  years  old,  wlio  walked  to  the  hospital  fourteen  days  after  the  acci- 
dent and  complained  only  of  slight  pain  in  the  hip.  At  her  death,  three 
weeks  later,  the  fracture  was  found  to  be  at  the  junction  of  head  and 
neck  with  sharp  angular  displacement,  apex  forward.  In  the  slighter 
cases  in  the  young  the  patients  have  sometimes  walked  for  several  days 
before  shortening  and  disability  suddenly  appeared.  See  Blecher 
(Deutsche  Zeitschrift  fur  Chir.,  vol.  77,  p.  302)  for  four  such  personal 
cases ;  the  patients  were  twenty  and  twenty-two  years  old,  and  the 
fracture  at  the  middle  of  the  neck. 

The  opposite  error,  that  of  supposing  a  fracture  to  exist  because  the 
limb  has  been  disabled  by  a  fall,  can  be  easily  made,  because  a  simple 
contusi()n  may  cause  eversion  of  the  limb  as  well  as  ecchymosis  and 
swelling,  and  in  some  cases  fracture  causes  no  other  symptoms  than 
these.  Observation  of  the  case  for  a  few  days  will  make  the  diagnosis 
clear. 

Pain  is  always  present.  It  is  usually  slight,  or  even  absent,  when 
the  patient  is  at  rest,  but  is  readily  excited  by  even  slight  communi- 
cated or  voluntary  movements.  It  is  referred  sometimes  to  the  region 
of  the  trochanter,  sometimes  to  the  groin  or  inner  and  upper  portion 
of  the  thigh.  Sometimes  pressure  with  the  end  of  the  finger  detects 
a  particularly  sensitive  point  in  the  line  of  the  neck  in  front  just  out- 
side the  great  vessels,  or  at  the  corresponding  point  behind.  Forcible 
pressure  upward  against  the  foot  or  inward  against  the  trochanter  fre- 
quently fails  to  cause  pain. 


FRACTURES  OF   THE  FEMUR.  381 

The  posture  and  appearance  of  the  Hmb  are  so  characteristic  that  it 
is  sometimes  ahiiost  safe  to  make  the  diagnosis  by  simple  inspection. 
As  tlie  patient  lies  npon  his  back  the  affected  limb  appears  shorter  than 
the  other,  everted,  and  slightly  flexed  and  abducted,  and  conveys  an 
impression  of  helplessness  that  is  often  very  striking.  The  upper  \)oy- 
tion  of  the  thigh  is  swollen  in  front  and  on  the  outer  side,  and  ecchy- 
mosis  sometimes  appears  after  a  day  or  two.  The  greater  the  shortening 
the  more  marked  is  this  swelling. 

Eversion  may  be  so  marked  that  the  foot  rests  entirely  u])on  its 
outer  border  as  the  patient  lies  upon  the  back.  In  other  cases  it  is  so 
slight  that,  as  Prof.  Bigelow  has  pointed  out,  it  is  best  recognized  by 
comparing  the  extent  to  which  the  two  feet  can  be  mverted. 

In  exceptional  cases  the  limb  is  inverted ;  it  is  either  found  so  on 
the  first  examination  or  it  becomes  so  after  a  day  or  two. 

The  cause  of  the  eversion  is  probably  almost  always  mechanical ;  it 
is  largely  the  effect  of  gravity  acting  upon  the  limb  under  changed 
conditions  of  support.  It  is  favored  by  angular  displacement  at  the 
fracture.  On  the  other  hand,  eversion  has  been  observed  in  cases  of 
simple  contusion,  and  in  others  of  fracture  in  which  there  was  no  dis- 
placement of  the  fragments,  no  rupture  of  the  periosteum  even,  and 
consequently  no  loss  of  support.  When  one  lies  upon  his  back  a  dis- 
tinct, although  slight,  effort  is  required  to  keep  the  toes  upright ;  the 
natural  tendency  of  the  limb  is  toward  eversion,  particularly  if  the 
knee  is  slightly  flexed,  and  this  tendency  which  is  increased  by  any- 
thing that  diminishes  the  activity  of  the  muscles  must  be  taken  into 
account  in  those  obscure  cases  where  the  diagnosis  lies  between  a  con- 
tusion and  a  fracture. 

The  cause  of  inversion  is  not  so  clear.  Smith  attributes  it  to  the 
position  of  the  fragments  relative  to  each  other,  and  says  that  in  all 
the  cases  of  inversion  which  he  was  able  to  examine  post  mortem  he 
found  the  lower  fragment  in  front  of  the  upper  one.  This,  however, 
does  not  always  explain  the  symptom  when  the  fracture  is  of  the  nar- 
row part  of  the  neck,  intracapsular,  although  it  may  do  so  in  some, 
as  in  the  case  observed  by  Goyrand  ^  where  the  neck  had  slipped  behind 
the  head  and  was  fixed  between  it  and  the  capsule. 

The  diagnostic  value  of  the  posture  of  the  limb,  as  regards  eversion 
or  inversion,  is  not  very  great,  for  inversion  is  a  symptom  that  needs, 
as  it  were,  to  be  explained  away,  and  eversion  may  be  due  to  a  simple 
contusion.  In  order  to  estimate  the  degree  and  persistence  of  the  ever- 
sion the  patient  should  be  placed  flat  upon  his  back  with  the  thigh  and 
leg  extended.  A  comparison  with  the  other  foot  will  then  show  the 
deo^ree  of  the  eversion,  and  p;entle  efforts  to  rotate  the  limb  will  show 
to  what  extent  and  in  what  manner  the  movements  are  restricted. 

Shortening  of  the  limb  is  produced  either  by  alteration  of  the  angle 
between  the  shaft  and  the  neck  or  by  overriding,  and  may  vary  in 
extent  from  a  small  fraction  of  an  inch  to  two  or  three  inches.  It 
may  be  present  at  its  maximum  immediately  after  the  accident,  or  it 
may  be  absent  at  first  and  appear  gradually  or  suchlenly  after  the  la])se 
of  a  few  hours  or  days,  or  may  increase  gradually  or  suddenly.    It  was 

1  Goyrand:  Diet.  Encyclopcclique,  art.  Cuisse,  p.  239. 


382 


FRACTURES. 


Fig.  269. 


formerly  held  that  when  the  fracture  is  of  the  narrow  part  of  the  neck 
(intracapsular)  the  shortening  is  absent  or  slight  at  first,  increases 
more  or  less  gradually,  and  never  exceeds  one  and  a  quarter  inches  ; 
and  gradual  increase  in  the  amount  of  shortening  is  claimed  by  some 
to  be  pathognomonic  of  this  variety  of  fracture.  These  statements  are 
true  only  as  an  expression  of  the  average  condition  ;  in  exceptional 
intracapsular  cases  the  shortening  may  exceed  this  amount,  and  in 
fractures  at  the  base  of  the  neck  it  may  increase  gradually  in  the  same 
manner.  Dietzer  {Deutsche  Zeitschrift  fur  Chir.,  vol.  64,  p.  63)  reports 
a  unique  case  of  lengthening,  2  cms. 

In  measuring  the  limbs  care  must  be  taken  to  have  them  form  the 
same  angle  with  the  pelvis,  that  each  is  in  the  same  position  of  exten- 
sion and  abduction.  If  the  injured  limb  cannot  be  brought  parallel 
to  the  median  line  of  the  body  the  other  must  be  abducted  to  the  same 
degree.  To  insure  this  symmetry  it  is  well  to  stretch  a  cord  downward 
at  right  angles  to  and  from  the  centre  of  another  cord  stretched  between 
the  two  anterior  superior  iliac  spines,  and  then  to  place  the  ankles  at 
equal  distances  from  it  and  as  near  to  it  as  is  convenient.  The  meas- 
urements are  usually  made  between  the  anterior  superior  spine  of  the 
ilium  and  a  malleolus. 

Another  method  of  recognizing  shortening  and  of  measuring  its 
extent  is  one  recommended  by  Mr.  Bryant,  measuring  to  the  trans- 
verse vertical  plane  passing 
through  the  anterior  superior 
spinous  processes.  Thus,  in 
Fig.  269  a  c  represents  the 
vertical  plane  passing  through 
these  processes,  and  b  is  the 
top  of  the  great  trochanter. 
In  fracture  of  the  neck  with 
shortening  b  is  brought  nearer 
to  e.  The  same  care  must  be 
taken  to  have  the  limbs  in 
symmetrical  positions,  and  I 
have  found  it  convenient  to 
mark  the  vertical  plane  by  placing  a  small  stick  or  pencil  upright  beside 
the  pelvis  and  in  line  with  the  processes,  and  then  to  measure  the  dis- 
tance between  it  and  the  trochanter.  The  same  measurement  can  be 
made,  roughly  but  usually  with  sufficient  accuracy,  by  placing  the 
thumbs  on  the  superior  iliac  spinous  processes  and  the  tip  of  a  finger 
on  each  trochanter,  and  thus  estimating  the  comparative  levels. 

Another  but  less  accurate  method  of  recognizing  the  elevation  of 
the  trochanter  is  to  find  its  position  with  reference  to  "  Nekton's  line," 
the  line  taken  by  a  cord  stretched  between  the  tuberosity  of  the  ischium 
and  the  anterior  superior  spine  of  the  ilium.  Under  normal  conditions 
this  line  crosses  the  top  of  the  trochanter  when  the  thigh  is  slightly 
flexed  on  the  pelvis. 

Attention  has  been  called  by  Dr.  Allis  to  an  effect  of  this  shortening 
which  can  be  easily  recognized  ;  the  relaxation  of  the  fascia  lata  between 
the  ilium  and  the  trochanter  and  just  above  the  knee  on  the  outer  side. 


Bryant's  ilio-femoral  triangle,  for  diagnosis  of  frac- 
ture of  the  neck  of  the  femur. 


FRACTURES  OF   THE  FEMUR.  ^8^ 

Another  effect  is  the  broadening  and  thickening  of  the  upper  por- 
tion of  the  thigh,  a  cliange  in  shape  which  the  eye  learns  to  recognize 
as  almost  pathognomonic. 

The  shortening  can  sometimes  be  overcome,  entirely  or  in  great  part, 
by  gentle  traction  upon  the  limb  combined  with  enongh  rotation  inward 
to  correct  such  aversion  as  may  exist.  I  think  the  dread  of  separating 
impacted  fragments  by  traction  has  been  exaggerated.  The  penetra- 
tion is  transverse,  and  longitudinal  traction  that  is  not  violent  enough 
to  cause  much  pain  cannot  do  more  than  change  the  angle  at  the  junc- 
tion of  the  neck  and  shaft,  it  does  not  separate  the  fragments  from  each 
other.  Rotatory  movements  communicated  to  the  limb  are  more  likely 
to  do  harm,  as  is  also  such  lack  of  support  as  will  allow  the  eversion 
and  shortening  to  be  increased. 

Crepitus  is  occasionally  perceived  during  the  manijMilation  of  the 
limb  while  making  either  traction  or  rotation,  in  the  latter  especially 
if -the  limb  is  at  the  same  time  flexed  ;  but  it  is  far  from  being  a  con- 
stant sign,  either  because  of  impaction  or  of  splintering  that  leaves  the 
pieces  too  closely  connected  to  produce  it.  The  sign  is  one  that  should 
not  be  repeatedly  sought  for ;  in  the  cases  that  are  really  obscure  it  is 
highly  improbable  that  it  can  be  obtained,  and  in  the  others  it  is  not 
needed.  The  failure  to  obtain  it  on  examination  has  led  to  many 
costly  errors  in  diagnosis. 

Among  other  signs  which  may  be  present  are  enlargement  of  the 
great  trochanter  when  it  has  been  split  or  comminuted,  or  the  appear- 
ance of  its  enlargement  by  the  inflammatory  thickening  of  the  over- 
lying soft  parts,  cliange  in  its  distance  from  the  median  line  of  the 
body  change  in  the  axis  of  rotation  of  the  limb,  and  the  change  in  the 
depressibility  of  the  outer  portion  of  Scarpa's  space. 

The  enlargement  of  the  trochanter  in  (ionsequence  of  its  having  been 
split  by  the  outer  end  of  the  neck  is  sometimes  very  marked  and  easily 
recognized  before  the  soft  parts  have  become  swollen  by  grasping  it 
between  the  thumb  and  fingers.  The  similar  enlargement  due  to 
infiltration  of  the  adjoining  soft  parts  is  always  present  in  fracture  at 
the  base  of  the  neck  after  a  day  or  two. 

The  distance  between  the  outer  face  of  the  trochanter  and  the  median 
line  of  the  body  may  be  increased  or  diminished,  but  the  change  is 
seldom  very  marked  and  is  difficult  of  accurate  determination.  It  is 
easier  to  prove  that  it  ought  to  exist  on  theoretical  grounds  than  to 
recognize  it  if  actually  present.  If  the  neck  is  driven  into  the  tro- 
chanter the  distance  of  the  trochanter  from  the  cotyloid  cavity  is  dimin- 
ished by  the  amount  of  the  penetration  ;  if,  on  the  other  hand,  then;  is 
no  penetration  or  crushing  and  the  displacement  is  an  angular  one  in 
the  frontal  plane,  the  bone  being  pushed  up  until  the  angle  at  the 
junction  of  the  neck  and  shaft  becomes  a  rigiit  angle,  the  distance  is 
increased  because  the  neck  then  stands  directly  out  from  the  body 
instead  of  being  inclined  downward  ;  and  thirdly,  in  combinations  of 
penetration  and  this  angular  displacement  the  two  changes  may  neu- 
tralize each  other  in  wdiole  or  in  ]>art. 

Rotation  of  the  trochanter  upon  a  shorter  radius  than  usual  is 
another  symptom  found  in  the  text-books  but  not  often  at  the  bed- 


3S4  FRACTURES. 

side.  Theoretically,  if  the  lever  upon  which  rotation  is  made  is  broken 
a  new  centre  is  formed  at  the  seat  of  fracture  or  the  radius  is  shortened 
by  impaction.  Nothing  could  be  simpler  or  more  accurate  in  theory, 
but  in  practice  it  is  beset  with  difficulties  that  make  it  worthless  as  a  sign, 
for  it  is  recognizable  only  in  cases  where  the  diagnosis  cannot  be  in  doubt. 

It  is  practically  impossible  to  tell  by  pressing  the  finger  against  the 
outer  face  of  the  trochanter  whether  it  rotates  upon  a  long  or  a  short 
axis,  for  the  range  of  permissible  motion  is  too  limited  to  make  it  pos- 
sible to  recognize  the  sharpness  of  its  curve.  In  cases  of  fracture  with 
crushing  of  the  neck  and  when  the  shaft  lies  unconnected  with  the 
remainder  of  the  neck  and  the  head,  rotation  of  the  limb  may  take 
place  about  the  longitudinal  axis  of  the  femur,  and  the  centre  of  motion 
lie  within  the  shaft,  not  outside  of  it  in  the  cotyloid  cavity,  and  this 
can  sometimes  be  recognized  by  pressing  the  finger  against  the  posterior 
face  of  the  trochanter  and  rotating  the  limb  gently.  Instead  of  rising 
from  the  finger  the  bone  may  be  felt  to  slide  over  it.  Or  pressure 
against  the  back  of  the  trochanter  may  simply  raise  it,  instead  of 
inverting  the  foot. 

The  change  in  the  depressibility  of  Scarpa^s  space  signalized  by 
Hennequin  ^  is  a  valuable  diagnostic  symptom.  Under  normal  condi- 
tions the  fingers  can  be  pressed  deeply  into  the  limb  in  the  outer  por- 
tion of  Scarpa's  space,  but  when  the  neck  of  the  femur  is  broken  this 
depressibility  is  reduced  in  varying  degrees,  apparently  by  the  angular 
displacement  (with  the  apex  directed  forward)  which  takes  place  so 
commonly  at  the  junction  of  the  neck  and  shaft  or  by  infiltration  of 
the  soft  parts.  The  same  condition  was  described  by  Laugier  ^  as  a 
sort  of  bony  tumor  to  be  felt  on  the  outer  side  of  the  great  vessels  an 
inch  or  two  below  Poupart's  ligament,  slight  pressure  upon  which  was 
painful. 

Diagnosis. 

In  most  cases  the  existence  of  a  fracture  of  the  neck  of  the  femur 
can  be  readily  determined  and  sometimes  its  variety  can  also  be  easily 
recognized,  but  in  others  the  main  character  of  the  injury  is  very 
obscure,  aud,  when  the  presence  of  fracture  is  e\'ident,  it  may  easily  be 
impossible  to  distinguish  positively  between  the  two  forms.  The  means 
by  which  they  may  be  distinguished  are  described  below. 

When  the  symptoms  described  above  are  clearly  marked,  when  there 
is  the  history  of  a  fall  followed  by  complete  loss  of  power  in  the  limb, 
with  shortening,  eversion,  crepitus,  pain  at  the  hip,  and  elevation  of 
the  trochanter,  there  can,  of  course,  be  no  doubt — the  neck  of  the 
femur  is  broken.  But  when  the  limb  is  not  entirely  powerless,  when 
the  shortening  and  eversion  are  slight,  perhaps  even  doubtful,  when 
crepitus  is  not  felt,  when,  in  short,  there  is  no  single  positive  sign,  the 
temptation  to  conclude  that  there  is  no  fracture  is  great,  and  although 
the  warning  uttered  by  Hodgson  nearly  a  century  ago,  that  inability 
in  an  elderly  patient  to  use  the  limb  after  a  fall  upon  the  hip  should 
be  deemed  evidence  of  probable  fracture  of  the  neck  of  the  femur,  has 

1  Hennequin:  Des  Fractures  du   Femur,   p.   700. 

^  Laugier:   Diet.  Encyclopedique,  art.  Cuisse,  p.  507. 


FRACTURES  OF   THE  FEMUR.  385 

been  repeated  many  times  since,  it  is  still  very  often  disregarded  to  the 
groat  damage  of  tlie  patient  and  sometimes  also  of  the  surgeon.  The 
rule  should  be  firmly  established  in  practice  that  every  doubtful  case, 
especially  in  the  elderly,  should  be  treated  at  first  as  a  fracture,  and  all 
the  more  so  if  the  violence  has  been  comparatively  slight,  such  as  a 
stumble  or  a  fall  while  walking.  It  has  been  said  that  the  pain  of  a 
contusion  or  sprain  is  most  marked  on  moving  the  limb,  that  of  a  frac- 
ture on  trying  to  bear  the  weight  of  the  body  upon  it ;  but  even  if  the 
statement  is  accurate,  which  I  doubt,  it  would  be  very  injudicious  to 
make  the  test,  for  if  fracture  is  present  the  effort  to  bear  the  wei2:ht 
upon  the  limb  would  be  likely  to  separate  the  fractured  surfaces  and 
increase  the  displacement  and  the  chances  of  failure  of  union.  If  the 
injury  is  not  a  fracture  the  rest  and  even  the  confinement  to  bed  can 
do  no  harm  and  are  but  a  small  price  to  pay  for  the  avoidance  of  the 
grave  risks  involved  in  the  neglect  of  the  precaution  so  long  as  it  is 
possible  that  the  injury  is  a  fracture. 

The  examination  should  be  directed  first  to  the  history  of  the  case, 
then  to  the  functions  of  the  limb  and  the  pain,  then  to  its  attitude  and 
length,  the  condition  and  height  of  the  trochanter,  and  the  depressi- 
bility  of  Scarpa's  space.  If  any  doubt  then  remains  the  limb  may  be 
gently  rotated,  in  order  to  judge  of  the  degree  of  eversion  and  of  its 
mobility,  and,  if  desired,  to  estimate  the  radius  of  rotation,  and  perhaps 
incidentally  to  elicit  crepitus. 

A  possible  source  of  error  in  the  existence  of  a  former  fracture,  or 
of  a  deforming  or  dry  arthritis,  to  which  a  fresh  contusion  has  just 
been  superadded,  must  be  borne  in  mind  when  the  history  of  the  case 
is  inquired  into. 

Dislocation  is  eliminated  in  case  of  eversion  by  noting  the  absence 
of  the  head  of  the  femur  from  the  pubic  region.  The  exclusion  of 
dislocation  backward  upon  the  ilium  in  case  of  fracture  with  inversion 
of  the  limb  may  be  more  difficult.  In  dislocation  the  limb  is  more  fixed, 
it  is  adducted  and  flexed,  the  trochanter  is  prominent,  the  head  of  the 
femur  may  perhaps  be  felt  posteriorly,  and  its  absence  from  the  cotyloid 
cavity  be  recognized  by  palpation.  In  fracture  the  inversion  may  give 
place  to  eversion  after  traction  upon  the  limb. 

Fracture  at  a  lower  level  is  recognized  by  the  seat  of  pain  on  direct 
pressure  and  usually  by  the  failure  of  the  trochanter  to  share  in  rota- 
tory movements  communicated  to  the  lower  portion  of  the  limb. 

Fracture  of  the  acetabulum  with  penetration  of  the  head  of  the 
femur  into  the  pelvis  has  usually  been  mistaken  for  fracture  of  the 
neck  of  the  femur.  The  means  of  diagnosis  has  been  mentioned  in 
the  preceding  chapter. 

In  regard  to  the  differential  diagnosis  between  fractures  through  the 
neck  (intracapsular)  and  those  at  the  base  (extracapsular)  it  can  only 
be  said  that  most  of  the  latter  can  be  positively  recognized  by  sensitive- 
ness on  pressure  along  the  line  of  fracture  and  by  the  thickening  recog- 
nized by  grasping  the  great  trochauter  between  the  thumb  and  fingers, 
a  thickening  due  either  to  splitting  of  the  trochanter  or  to  infiltration 
of  the  overlying  soft  parts  starting  from  the  fracture  ;  and  some  of  the 
former  almost  as  positively  by  exclusion  aided  by  the  age  of  the  patient, 


386 


FRACTURES. 


the  slight  violence,  the  absence  of  thickening  and  sensitiveness  to 
pressure  about  the  base  of  the  neck,  and  the  absence  or  the  slight 
amount  of  the  shortening,  but  in  many  cases  the  distinction  cannot  be 
made.  Thickening  about  the  trochanter  and  base  may  be  a  little  de- 
layed. Anaesthesia  makes  the  recognition  of  some  of  the  signs  easier, 
but  is  likely  to  lead  to  unnecessary  handling  and  to  increase  the  dis- 
placement. 

In  the  young,  before  shortening  and  disability  have  occurred,  a  posi- 
tive diagnosis  without  the  aid  of  the  .r-rays  may  be  impossible. 

Prognosis. 

In  this  must  be  considered  the  immediate  danger  to  the  life  of  the 
patient  created  by  the  accident,  and  the  remoter  influence  upon  the 
functions    of  the    limb.      In  five    years  during  which   the    published 

records    of  the  New   York 
^^^•270.  Hospital     differentiate     be- 

tween fractures  of  the  neck 
and  of  the  shaft  thirty-three 
cases  of  the  former  were  re- 
ceived, with  one  death;  but 
as  the  average  stay  was  only 
thirty  days,  it  is  probable 
that  fully  half  of  them  were 
transferred  to  other  institu- 
tions within  a  day  or  two 
after  their  receipt,  and  the 
actual  mortality  was  greater. 
Ashhurst  and  Newell,^  tab- 
ulating the  cases  received 
during  three  years  at  the 
Episcopal  Hospital,  Phila- 
delphia, found  fifty-eight  ca- 
ses with  sixteen  deaths. 

The  promptly  fatal  cases 
present  three  principal  forms: 
in  one  the  primary  inflamma- 
tory reaction  is  sharp,  fever 
sets  in,  the  patient  becomes 
delirious  and  dies  within  a 
few  days,  or  pneumonia  is 
developed  soon  after  the  ac- 
cident and  proves  fatal.  In  another  the  patient,  old  and  feeble,  seems 
overwhelmed  by  the  mental  and  physical  shock  and  dies  within  two  or 
three  days.  lu  the  third  form  the  patient's  strength  fails  rapidly  with- 
out much  inflammatory  reaction  from  the  injury,  and  he  dies  asthenic, 
with  mild  delirium,  and  usually  with  some  pulmonary  consolidation, 
about  the  third  week.     It  is  possible  that  fat  embolism,  especially  of  the 


Ununited  fracture  of  the  neck  of  the  femur,  showing  the 
hypertrophied  outer  fasciculous  of  the  Y-ligament  support- 
ing the  weight  of  the  body  in  waliiing.    (Bigei.gw.) 


1  Ashhurst  and  Newell:  Annals  of  Surgery,  1908,  vol.  48,  p.  748. 


FRACTURES  OF  THE  FEMUR. 


387 


Fig.  271. 


lungs,  may  be  an  important  factor  in  producing  this  result.  The  influ- 
ence of  age  upon  the  prognosis  is  very  well  marked,  the  older  the  patient 
the  greater  the  probability  of  a  fatal  termination  within  a  few  weeks. 

The  influence  of  the  seat  of  the  fracture  upon  the  prognosis  in  respect 
of  repair  has  been  discussed  above.  Speaking  generally,  union  may  be 
confidently  expected  in  frac- 
tures at  the  base  of  the  neck, 
and  I  believe  that  it  is  much 
more  common  after  fracture 
through  the  neck  than  has 
been  supposed,  and  that  this 
frequency  can  be  increased  by 
appropriate  treatment.  But, 
on  the  other  hand,  union 
takes  jalace  almost  inevitably 
with  some  deformity  and  with 
some  limitation  of  motion  at 
the  hip ;  the  limb  is  short- 
eued  and  everted,  and  abduc- 
tion is  diminished  by  the 
change  in  the  angle  of  the 
neck  with  the  shaft.  This 
shortening  may  be  slight,  but 
it  causes  more  of  a  limp  than 
an  equal  amount  in  the  line 
of  the  shaft  does,  because  a 
compensatory  abduction  of 
the  limb  is  not  so  easily  made. 
The   limitation  of  motion  is 

seldom  enough  to  cause  much       "^^^  same,  seen  from  behind,  showing  the  tense  obtn- 
1      ...        •    •     ,    rator  tendon  and  the  hypertrophied  inferior  gemellus. 

inconvenience,  but  the  joint  (Bigelow.) 

may  be  sensitive  to  fatigue 

and  weather  and  may  even  be  persistently  painful.     Very  satisfactory 

usefulness  is  possible  even  in  advanced  age. 

Failure  of  union — bony  or  fibrous — does  not  necessarily  cause  com- 
plete disability.  There  are  a  number  of  specimens  of  complete  failure 
of  union  obtained  from  patients  who  have  made  considerable  use  of  the 
limb  for  several  years  after  the  fracture;  they  show  usually  complete 
disappearance  of  the  neck  and  smooth  opposing  surfaces  on  the  head 
and  side  of  the  shaft.  One  of  Bigelow's  specimens  shows  a  similar 
condition  with  marked  displacement  upward  of  the  shaft,  the  weiglit  of 
the  body  having  apparently  been  borne  iqion  it  by  sus])ensi()n  through 
the  Y-ligament  and  the  obturator  and  inferior  gemellus.  Among  later 
specimens  reported  with  interesting  details  are  two  by  lieboul^  and  one 
by  Bryce."  In  such  cases  that  have  come  under  my  observation  the 
usefulness  of  tlie  limb  has  been  slight,  althoiu^h  there  was  good  motion 


'  Reboul:   Bull,  de  la  Sof.  Anat.,  May  25,  1888. 
2Bryce:  Glasgow  Medical  Journal,  .July,  1892. 


388  FRACTURES. 

and  little  or  no  pain;  the  patient  walks  with  a  marked  limp,  only  with 
the  aid  of  a  cane  or  crutch,  and  usually  bearing  the  weight  only  moment- 
arily upon  the  limb.  In  the  case  represented  in  Fig.  266  the  patient 
walked  without  a  cane.  In  other  cases  the  pain  has  been  so  great 
and  constant  that  excision  of  the  upper  fragment  has  been  done  for  its 
relief. 

Occasionally,  especially  in  the  old  and  rheumatic,  the  joint  remains 
stiiF  and  painful  even  after  union  has  taken  place,  and  sometimes  the 
new  formation  of  bone  upon  and  about  the  trochanter  is  so  great  that 
it  notably  restricts  motion  in  the  joint. 

Ashhurst  and  Newell  (above  quoted)  traced  21  cases  ;  of  these,  5  had 
a  "  perfect  functional  result "  (no  limp ;  2  apparently  were  children),  8 
had  "  no  disability^but  limp,"  6  had  "marked  impairment  of  function" 
(could  walk  with  aid  of  cane  or  crutch),  and  2  were  "  incapacitated." 

Mr.  Bryant's  ^  statement  that  all  his  hospital  cases  for  many  years 
(forty-two  cases,  average  age  seventy)  "went  out  with  good  and  useful 
limbs  "  indicates  results  much  better  than  any  others  I  have  knowledge 
of.  even  if  his  standard  of  "good  and  useful"  is  only  that  the  patient 
can  stand  and  walk  a  little  with  the  aid  of  a  cane. 

The  coxa  vara  which  is  seen  after  some  separations  of  the  epiphysis 
or  fractures  close  to  the  head  in  the  young  is,  sometimes  at  least,  due  to 
late  changes  in  the  shape  of  the  neck  (Fig.  246)  which  are  thought  to 
be  the  effect  of  the  changed  stresses  of  pressure  upon  the  growth  of  the 
bone. 

Treatment. 

In  respect  of  some  details  of  treatment  it  is  necessary  to  discriminate 
sharply  between  elderly  patients  who  furnish  the  great  majority  of 
the  cases  and  young  patients,  both  because  of  the  difl'erence  in  risk 
to  life  and  because  of  important  differences  in  pathological  details.  In 
the  young,  relatively,  the  line  of  fracture  is  usually  clean,  often  close 
to  the  head,  the  displacement  is  slight,  the  periosteum  of  the  neck 
untorn.  They  bear  anaesthetics  and  confinement  well,  and  the  injury 
creates  little  or  no  danger  to  life  and  comparatively  little  to  limitation 
of  function  by  arthritic  or  periarthritic  reactions.  In  the  old  the 
bone  has  already  been  weakened  and  rprefied  by  senile  change  and  the 
fracture  is  consequently  accompanied,  especially  at  the  base  of  the 
neck  where  it  most  frequently  occurs,  by  much  crushing.  To  this 
actual  loss  of  tissue  is  added  that  occasioned  by  the  rarefaction  of  the 
first  stage  of  repair,  a  process  which  in  this  region  is  exceptionally  well 
marked.  Consequently  an  ideal  anatomical  restoration  of  form  is 
impossible,  and  the  surgeon  must  be  content  to  get  union  with  a 
shortened  neck  and  probably  with  change  in  the  angle  which  it  makes 
with  the  shaft.  And,  in  addition,  intra-  and  periarticular  changes 
set  up  by  the  trauma  may  be  expected  to  limit  function.  Then,  too, 
there  is  a  definite  danger  to  life,  due  in  part  to  the  trauma,  in  part  to 

1  Bryant:  Lancet,  1880,  vol.  i,  p.  160,  and  British  Medical  Journal,  Oct.  12,  189.5,  p.  889. 


FRACTURES  OF   THE  FEMUR.  389 

the  imposed  confinement  and  the  pain.  The  first  indication  is  to 
save  life,  the  second  to  get  union,  the  third  to  correct  or  diminish 
displacements,  and  the  relative  prominence  of  these  indications  will 
vary  in  individual  cases. 

The  frequency  of  defective  results  in  these  cases,  that  is,  the  fre- 
quency with  which  elderly  patients  show  more  or  less  disability  due  to 
shortening  and  limitation  of  motion,  has  been  at  times  made  a  basis 
of  reproach  for  inadequate  or  unskilful  treatment  and  has  sometimes 
been  used  as  an  argument  against  the  methods  which  have  resulted  in 
them.  This,  in  view  of  the  pathological  and  clinical  facts  above 
referred  to,  is,  I  think,  unfair.  No  method  of  treatment,  in  my  judg- 
ment, can  certainly  overcome  the  actual  destruction  of  a  portion  of  the 
bone  by  the  trauma  and  the  rarefaction,  and  in  a  Jiot  inconsiderable 
proportion  of  cases  measures  which  might  possibly  somewhat  diminish 
the  permanent  change  cannot  properly  be  em*ployed  if  due  consideration 
is  given  to  the  preservation  of  life.  And  further,  I  am  convinced  that 
a  large  part  of  the  shortening  so  commonly  seen  is  the  result  not  of 
inadequate  treatment  of  the  fracture  during  the  first  two  months  but, 
on  the  contrary,  of  a  too  early  use  of  the  limb,  under  which  I  have  seen 
shortening  rapidly  increase  more  than  an  inch.  Indeed  I  know  of  one 
case  which  was  reported  as  without  shortening  by  a  new  method  of 
treatment  and  which  shortly  afterward  showed  shortening  of  an  inch 
and  a  quarter. 

The  principles  of  treatment  are  clear  and  the  means  by  which  they 
can  be  effectively  applied  are  simple  and  even  varied.  The  result, 
assuming  the  treatment  to  have  been  intelligent  and  watchful,  should 
in  almost  all  cases  of  fracture  at  the  base  of  the  neck  be  solid  union; 
the  degree  and  freedom  of  motion  will  vary  with  the  amount  of  peri- 
articular and  articular  reaction,  and  the  pain  with  the  constitutional 
type  of  the  patient. 

In  fractures  through  the  narrow  part  of  the  neck  union  will  depend 
largely  upon  the  extent  to  which  the  periosteum  has  been  torn  and 
consequently  the  nourishment  of  the  head  affected.  A  good  result  in 
these  cases  is  much  rarer.  The  degree  of  readjustment  in  these  cases  is 
largely  a  matter  of  chance  because  of  the  impossibility  of  intelligently 
modifying  the  position  of  the  head  if  that  should  be  faulty.  In  the 
young  and  middle-aged  the  outlook  is  better;  in  the  young  even  the 
relatively  frequent  fracture  close  to  the  head  may  be  expected  to 
reunite  if  the  fragments  are  in  apposition.  But  in  any  case  a  good 
result  at  the  end  of  active  treatment,  two  or  three  months,  may  be 
spoiled  by  too  early  use  of  the  limb. 

Reduction  involves  the  correction  of  shortening  and  usually  of 
external  rotation.  Complete  reduction  is  usually  possible  if  sufficient 
force  is  used;  but  it  is  not  always  desirable,  for  gaps  due  to  crushing 
of  the  bone  may  thereby  be  created,  gaps  which  the  elderly  patient 
might  well  be  unable  to  fill  with  new  bone.  Gaps  created  by  correction 
of  the  shortening  can  be  recognized  with  the  aid  of  .r-rays ;  those  created 
by  rotation  cannot  be,  because  of  interposition  of  the  bone  in  the  line 


390 


FRACTURES. 


of  the  rays.  The  presence  or  absence  of  the  latter  must  therefore 
remain  unknown,  but  it  seems  to  me  probable  that  nothing  short  of 
forcible  rotation  against  recognizable  resistance  would  create  it,  for 
the  rotation  of  the  limb  takes  place  far  more  easily  about  the  head  of 
the  femur  as  a  center  than  about  the  long  axis  of  the  shaft.  The 
interlocking  of  the  fragments  is  usually  sufficient  to  hold  them  together, 
and  the  communicated  rotation  does  not  affect  their  relations  to  each 
other  until  after  the  limit  of  motion  in  the  joint  has  been  reached. 

Fig.  272. 


Combined  suspension   and   traction, 


The  belief  that  these  relations  can  be  intelligently  modified  by  manip- 
ulation, even  under  an  anaesthetic  is,  I  think,  unjustified.  The  surgeon 
then  must  be  content  in  the  general  run  of  cases  to  correct  the  short- 
ening by  traction,  either  immediate  forcible  or  continued  moderate, 
and  to  make  internal  rotation,  if  at  all,  very  carefully  and  moderately. 
The  persistence  of  some  external  rotation  is  not  a  cause  of  disability. 
The  most  important  thing,  when  the  fracture  is  in  the  narrow  part  of 
the  neck,  is  to  do  nothing  which  will  tear  the  portion  of  the  periosteum 
which  has  remained  untorn,  for  upon  its  integrity  depends  the  ability 
of  the  head  to  share  in  the  process  of  repair.      It  is  wiser  to  abstain 


PLATE  XXII 


Fig.  1. — Fraeture   of  Neek   of  Femur  in  a   Boy,  aged,  sixteen. 


28 


Fig.  2. — The  same  as    Fig.  1,  after  traction. 


FRACTURES  OF   THE  FEMUR.  391 

from  an  attempt — at  best  a  blind  one — to  correct  moderate  external 
rotation  than  to  endanger  reunion. 

In  the  young,  and  under  the  guidance  of  the  .r-rays,  forcible  correction 
under  ether  in  fractures  at  the  base  of  the  neck  may  be  more  safely 
undertaken,  but  my  personal  experience  includes  no  cases  in  which 
the  desired  result  could  not  be  equally  well  obtained  by  continuous 
traction.  Of  course  if  the  case  is  to  be  later  treated  by  encasement  in 
plaster  reduction  must  be  effected  before  the  plaster  is  applied. 

The  stress  that  has  been  laid  by  some  upon  the  maintenance  of 
abduction  of  the  limb  during  treatment  is  misleading.  Moderate 
abduction  in  the  joint  is  always  present  under  efficient  traction,  even 
when  the  limb  lies  parallel  to  the  long  axis  of  the  body,  for  the  pelvis 
tilts  upon  the  spine;  extreme  abduction  is  more  likely  to  do  harm  than 
good,  for  what  in  some  cases  may  perhaps  be  gained  by  its  pressing 
the  fragments  together  is  more  than  offset  by  the  solicitation  of  shorten- 
ing by  the  tense  adductors  or,  if  that  is  prevented,  by  the  injury  to 
those  muscles  occasioned  by  their  prolonged  overstretching,  a  fibrotic 
change  with  loss  of  volume  and  power.  I  have  occasionally  found  it 
easier  to  make  satisfactory  reduction  by  traction  in  adduction,  but 
that  position  cannot  be  conveniently  maintained  dm-ing  repair. 

Retention  has  for  its  object  to  maintain  the  position  of  the  limb 
against  the  displacing  action  of  the  muscles  and  gravity,  to  keep  the 
fractured  surfaces  in  contact,  and  at  the  same  time  to  permit  a  certain 
general  freedom  of  motion  to  the  patient  which  will  facilitate  the  atten- 
tions necessary  to  meet  his  wants,  preserve  cleanliness,  avoid  bed-sores, 
and  diminish  the  general  ill  effects  of  restraint.  The  means  employed, 
in  their  order  of  frequency,  are  continuous  traction,  immobilization  by 
splints  with  or  without  direct  pressure  upon  the  trochanter,  and  fixation 
of  the  fragments  by  nails  or  sutures. 

It  has  long  been  noted  that  satisfactory  functional  results  can  some- 
times be  obtained  by  simple  rest  in  bed  for  a  few  weeks  with  only  such 
support  for  the  limb  as  can  be  given  by  cushions  or  a  long  side-splint 
without  traction  or  a  double  inclined  plane,  but  it  is  always  advisable 
and  sometimes  absolutely  necessary  to  use  means  which  will  more  surely 
give  the  necessary  immobilization  in  the  proper  position. 

Continuous  traction  can  be  made  by  weight  and  pulley  (Buck's 
extension),  or  by  Hodgen's  suspended  splint,  or  by  a  combination  of 
the  two,  or  in  combination  with  a  long  side-splint  or  hip-splint.  The 
details  of  their  application  are  given  in  Chapter  ATI.  If  Buck's  ex- 
tension is  used  the  foot  and  leg  should  lie  upon  a  A'olkmann's  siiding- 
rest  (Fig.  56)  to  promote  comfort  and  oppose  eversion  of  the  limb, 
and  a  small  firm  cushion  should  be  placed  behind  the  trochanter. 
Direct  pressure  upon  the  outer  aspect  of  the  trochanter  to  press  the 
fragments  together  can  be  made  by  a  padded  band  about  the  pehis. 
The  weight  varies  from  five  or  ten  pounds  in  the  old  to  fifteen  or 
twenty  in  the  young  adult.  If  Hodgen's  splint  (Fig.  59)  is  used,  the 
traction  can  be  made  greater  or  less  by  changing  the  angle  of  the 
supporting  cord;  thus,  in  the  old  its  upper  attachment  should  usually 


392  FRACTURES. 

be  about  a  foot  beyond  the  vertical  (at  a  height  of  about  five  feet),  and 
more  if  more  traction  is  desired.  The  Umb  should  swing  just  free  of 
the  bed,  somewhat  abducted.  The  Hodgen  splint  greatly  promotes 
the  patient's  comfort  and  is  generally  to  be  preferred,  I  think,  to  the 
other  methods  of  traction.  In  this  statement  I  include  its  use  for 
simple  vertical  suspension  while  traction  is  made  by  Buck's  extension 
(combined  suspension  and  traction,  Fig.  272). 

Hennequin  ^  makes  traction  by  a  band  crossing  the  front  of  the  thigh 
close  above  the  knee  and  passing  across  and  behind  the  upper  part  of 
the  partly  flexed  leg,  the  thigh  being  supported  in  a  wire  gutter.  The 
leg  and  foot,  thickly  wrapped  in  cotton,  rest  on  a  chair  beside  the  bed, 
or  in  a  gap  made  by  cutting  out  the  lower  part  of  the  mattress  on  that 
side. 

Outward  traction  upon  the  upper  part  of  the  thigh,  by  weight  and 
pulley  and  a  band  passing  about  the  inner  side  of  the  thigh,  has  been 
occasionally  employed.  I  doubt  both  its  efficiency  and  its  advisability 
if  efficient ;  the  former  because  of  the  opposition  of  the  adductors 
which  should  be  made  relatively  tense  by  the  longitudinal  traction,  and 
the  latter  because  if  there  is  any  crushing  a  gap  might  be  created 
between  the  fragments  which  would  endanger  union.  Ruth,^  who 
strongly  recommends  it  and  reports  many  excellent  results,  precedes  it 
with  forcible  correction  of  the  displacement  while  the  hip  is  flexed  at  a 
right  angle,  to  which,  perhaps,  any  superiority  in  result  which  may 
exist  should  be  attributed. 

The  combination  of  continuous  traction  and  immobilization  by  a 
splint  is  effected  in  various  ways.  The  older  method  was  the  long 
single  or  double  side-splint  with  elastic  traction,  as  shown  in  Fig.  61. 
Its  objectionable  feature  is  the  general  restraint  and  immobility  which 
it  imposes  and  which  the  aged  do  not  bear  well 

The  various  metal  splints  designed  for  use  in  hip-joint  disease  have 
of  late  come  into  some  use  in  the  treatment  of  these  fractures,  and  this 
use  might,  I  think,  be  advantageously  extended,  certainly  in  the 
younger  cases.  Such  an  apparatus  can  be  used  shnply  for  immobili- 
zation, as  in  the  Thomas  splint,  or  combined  with  traction  in  the  usual 
manner.  With  its  aid,  especially  if  supplemented  by  a  pelvic  band 
or  a  pad  to  press  upon  the  trochanter,  the  patient,  if  not  too  old  and 
feeble,  can  leave  the  bed  by  the  fourth  or  fifth  week,  sometimes  even 
earlier,  and  go  about  on  crutches.  Shaffer  ^  has  reported  two  very  inter- 
esting and  suggestive  cases  in  which  by  the  aid  of  such  a  splint  with 
traction  and  trochanteric  pressure  he  obtained  good  union,  although 
treatment  was  begun  in  one  three  months,  in  the  other  nine  months, 
after  the  receipt  of  the  injury. 

Encasement  of  the  limb  and  pelvis  in  plaster  of  Paris  was  freely  used 
in  New  York  for  a  few  years  after  1870  but  fell  into  disuse  because  of 
the  sloughs  occasionally  caused  and  because  the  more  rigid  confinement 
and  immobility  of  the  body  which  it  entailed  were  ill  borne  by  the 

1  Hennequin:  Fractures  des  os  longs,  1904. 

2  Ruth:  Therapeutic  Gazette,    March    15,    1907. 

3  Shaffer:  Nsw  York  Medical  Journal,  October  23,  1897,  p.  557. 


FRACTURES  OF   THE  FEMUR.  393 

aged.  Of  late  it  has  again  come  into  some  favor  by  virtue  of  modi- 
fication in  its  application.  By  fairly  wide  abduction,  and  especiall>- 
by  inclusion  of  both  lower  limbs,  in  abduction,  with  a  large  fenestra 
exposing  the  upper  inner  portion  of  the  thighs  and  the  region  above 
and  about  the  anus.  The  causation  of  sloughs  in  the  perinemn  is 
avoided,  and  I  am  told  that  patients  thus  dressed  bear  the  confinement 
well. 

In  principle  suspension  dressings  are  much  to  be  preferred  to  those 
that  are  more  confining.  They  add  to  the  comfort  of  the  patient  and 
diminish  the  later  stiffness  of  the  joints,  and  if  properly  used  no  well- 
founded  charge  of  defective  immobilization  of  the  fragments  can  be 
made  against  them. 

Cotton^  claims  benefit  in  fracture  through  the  narrow  part  of  the 
neck  from  preliminary  forcible  impaction  of  the  fragments  by  blows 
upon  the  trochanter  under  the  guidance  of  the  a:-rays. 

The  apparent  advantage  of  a  dressing  that  permits  the  patient 
promptly  to  leave  the  bed  is  illusory  in  most  cases,  for  the  patients  are 
too  old  and  feeble  to  profit  by  it ;  those  that  may  seem  to  need  the 
change  most  are  the  least  able  to  make  it,  in  the  others  the  gain  does 
not  seem  to  me  to  compensate  for  the  risk.  In  fractures  through  the 
neck,  and  in  others  in  which  the  transformation  of  the  bond  of  union 
into  bone  is  delayed  such  a  dressing  has  great  advantages,  for  it  ]>er- 
mits  the  patient  to  leave  the  bed,  say  in  the  second  or  third  month, 
without  interruption  of  the  immobilization. 

Prof.  Dollinger  reported  at  the  Congress  of  the  International  Sur- 
gical Society  at  Brussels  in  1911  that  he  had  used  an  ambulatory  dress- 
ing, either  of  plaster  of  Paris  or  an  elaborate  one  of  leather  and  steel, 
in  7  cases;  3  were  able  immediately  to  walk,  2  walked  after  several 
days,  and  2  could  not  walk  at  all  with  it.  The  ultimate  shortening 
was  from  1  to  3  c.c. 

Whatever  dressing  may  be  used,  a  most  important  factor  in  maintain- 
ing the  result,  if  that  be  good  or  even  moderate  in  respect  of  shortening, 
is  abstention  from  the  use  of  the  limb  for  weight-bearing  for  four  or  five 
months  from  the  date  of  the  accident.  Apparently  no  other  fracture 
requires  so  mu(;h  time  for  solid,  permanent  repair,  presumably  because 
no  other  is  so  exposed  in  use  of  the  limb  to  a  constant  cross-strain. 
Under  this  strain  angulation  takes  place  at  the  point  of  union  with 
consequent  shortening.  I  have  seen  excellent  results  seriously  deterior- 
ate through  lack  of  this  precaution.  I  do  not  mean  that  the  abstention 
should  be  absolute  :  the  toe  may  touch  in  walking  with  crutciies,  and 
little  by  little,  a  step  or  two  at  a  time,  the  weight  may  be  allowed  to 
rest  on  it,  but  the  full  weight  should  not  regularly  be  borne  until  after 
several  months. 

The  attempt  to  secure  union  by  operation,'-  in  fresh  as  well  as  in 

1  Cotton:  Annals  of  Surg.,  March,  1916,  p.  336. 

2  Konig,  Chirurgie,  5th  Ed.,  vol.  3,  p.  2.S2;  Loretta,  Brit.  Med.  Journ.,  .4ur.  25,  1888; 
Cheyne,  Ibid.,  March  7,  1892;  Dollinger,  Centralblatt  fiir  Chir.,  June  6,  1892;  Meyer, 
Annals  of  Surg.,  July,  1893;  Kocher,  Wichtiger  Frakturformen,  j).  303;  I'^reeniaii,  Annal.s 
of  Surg.,  Oct.  1904,  p.  561;  Fritz  Konig,  Arch,  fur  klin,  Chir.,  vol.  7(i,  p.  725;  Schlaiige, 
Ibid.,  vol.  81,  part  2,  p.  26;  Vaughan,  Am.  Journ.  Med.  Sci.,  March,  1907,  p.  385;  Ilerz, 
Ztlblatt.  fur  Chir.,  1906,  p.  705;  Flint,  Annals  of  Surg.,  1908,  vol.  48,  p.  729. 


394  FRACTURES. 

old  cases,  has  been  made  many  times  since  Lagenbeck's  first  and  unsuc- 
cessful one.  The  first  success  was  got  by  Franz  Kouig  in  1875  by 
passing  a  metal  pin  through  the  trochanter,  neck,  and  head,  and  most 
subsequent  ones  have  been  got  in  the  same  way. 

The  weight  of  opinion,  to  judge  from  the  published  papers  and 
reports  of  discussions  in  various  surgical  societies,  is  strongly  in  favor 
of  abstention  in  fractures  at  the  base  of  the  neck.  The  occasional  suc- 
cesses obtained  in  old  cases  are  matched  by  those  obtained  by  splints. 

In  fracture  through  the  narrow  part  of  the  neck  the  question  is  still 
an  open  one  and  presents  itself  in  two  forms  :  Shall  the  attempt  be 
made  in  a  fresh  fracture  ?  Shall  it  be  made  in  an  old  fracture  or  shall 
excision  of  the  head  be  preferred?  Here,  too,  the  weight  of  opinion 
has  been  decidedly  against  operation  in  fresh  cases,  and  seems  to  be 
fully  justified  by  the  known  pathology  of  the  injury  and  the  belief 
that  the  preservation  of  the  blood  supply  of  the  head  is  essential  to 
repair.  Suturing  the  periosteum,  if  it  has  been  torn,  cannot  be  ex- 
pected to  restore  this  blood  supply  sufficiently  soon  and  abundantly  to 
do  anv  good  ;  and  if  the  periosteum  has  not  been  torn,  suturing  of  the 
bone  is  superfluous  and  correction  of  the  angular  displacement  will 
only  open  a  gap  on  the  concave  side  which  will  diminish  the  breadth 
and  consequently  the  strength  of  such  union  as  may  be  obtained. 
Fritz  Konig,  after  four  attempts  at  late  suture,  got  a  good  result  in  an 
early  one  and  obtained  the  specimen  a  few  months  later.  He  found 
firm  union  (bony  ?)  in  front  where  he  had  sutured  bone  and  periosteum, 
and  a  gap  behind  where  he  had  placed  no  sutures,  and  on  the  strength 
of  this  he  argues  for  operation  at  the  end  of  the  first  week  and  for 
suturing  all  around,  attributing  the  gap  to  the  absence  of  sutures.  It 
c-an,  with  greater  plausibility,  I  think,  be  charged  to  correction  of  the 
displacement.  Late  attempts  to  get  union  have  given  few  results  that 
can  be  called  even  moderate  successes,  and  Ivonig's  opinion  that  if  it 
is  to  be  done  at  all  it  should  be  done  early  is  doubtless  correct.  The 
Atlee  bone  pin  or  inlay  seems  preferable  to  one  of  metal. 

Excision  of  the  head^  in  old  cases  for  the  relief  of  pain  and  improve- 
ment of  function  has  given  a  nmnber  of  good  results.  For  the  attempt 
to  get  union  and  also  for  excision  Fritz  Konig  recommends  the  anterior 
approach  by  an  incision  between  the  tensor  vaginse  femoris  on  one 
side  and  the  rectus  and  sartorius  on  the  other.  Ito  and  Asahara,  for 
excision,  used  the  posterior  route,  the  Langenbeck  or  Kocher  incision. 

C.  Fractures  Through  the  Great  Trochanter  and  Neck. 

(Fractura  Pertrochanterica,  Kocher.) 

This  class  may  be  defined  as  composed  of  those  cases  in  which  the 
line  of  fracture  begins  at  or  near  the  lower  part  of  the  junction  of  the 
neck  and  shaft  and  passes  through  or  close  below  the  great  trochanter, 
dividing  the  bone  into  two  parts,  of  which  the  upper  is  formed  by  the 

1  Howe,  Med.  Record,  vol.  14,  p.  394;  Fritz  Konig,  Chirurgie,  vol.  3,  p.  2.52:  Lejars, 
Semaine  med.,  Oct.  17,  1894;  Bolton,  Annals  of  Surg.,  Feb.,  1900,  p.  149,  Ito  and 
Asahara,  Deutsche  Zeitschrif t  fiir  klin.  Chir.,  vol.  78,  p.  121,  7  cases;  Fritz  Konig,  loc.  cit. 


FRACTURES  OF   THE  FEMUR. 


395 


head,  neck,  and  upper  part  of  the  trochanter.  The  hne  of  fracture 
may  be  obhque  from  withm  outward  and  upward,  or  from  behind 
upward  and  forward.  The  Hne  of  division  between  these  and  the 
subtrochanteric  fractures,  the  highest  of  the  fractures  of  the  shaft,  is 
marked  by  the  trochanter  minor,  which  also  establishes  an  important 
clinical  difference,  depending  upon  the  action  of  the  psoas-iliacus  which 


Fig.  273 


Fig.  274. 


Pertrochanteric  fracture.    (Kocher.) 


Pertrochanteric  fracture.    (Kocher.) 


is  attached  thereto.  Its  action  in  fractures  below  that  point  is  to  flex 
the  npper  fragment. 

The  injury  is  not  a  common  one,  and  the  recorded  specimens  are 
few.  To  those  described  in  the  first  edition  may  be  added  three  from 
the  museum  of  Trinity  College,  Dublin,  shown  by  Bennett  ^  to  the 
British  Medical  Association,  five  described  and  figured  by  Kocher, 
and  one  in  the  U.  S.  Army  Med.  Museum  (Fig.  275).  The  illustra- 
tions of  Bennett's  are  so  indistinctly  printed  that  the  details  are  not 
recognizable.  Kocher's^  specimens  show  marked  angular  deformity, 
apex  forward,  and  some  diminution  of  the  angle  of  the  neck,  adduction 
of  the  shaft  (Figs.  273  and  274). 

The  only  one  I  have  seen  differed  notably  from  the  type-form  in 
that  the  line  of  fracture  was  very  long  and  oblique,  extending  from  the 
top  of  the  trochanter  downward  and  inward  to  a  point  which  I  thought 
was  well  below  the  lesser  trochanter.  Because  of  persistent  displace- 
ment and  some  uncertainty  of  diagnosis  I  exposed  the  fracture  by  an 
anterior  incision,  but  did  not  uncover  its  lower  end.  The  patient  was 
fifty  years  old,  and  recovered  with  little,  if  any,  shortening. 


1  Bennett:  Brit.  Med.  Jour.,  Oct.  12,  1.S9.5,  p.  893. 

2  Kocher:  Loo.   cit.,   Figs.    14U,    1.51-1.57. 


FRACTURES. 


The  mechanism  appears  to  be  forcible  extension  (possibly  abduction) 
of  the  limb,  in  which  movement  the  neck  and  trochanter  are  arrested 
by  the  Y-ligament  and  the  fracture  takes  place  below  or  through  its 
lower  attachment. 

The  characteristic  symptom  appears  to  be  the  prominence  of  the 
angle  in  front,  with  pain  on  pressure  at  this  point,  and  possibly  with 


Fig.  275. 


Pertrochanteric  fracture  ;  rear  view. 
Fig.  276. 


Pertrochanteric  front;  front  view.    (U.  S.  Army  Mtd.  Museum.) 

immobility  of  the   trochanter  and  crepitus  when  the  limb  is  gently 
rotated.     Shortening  and  ever.sion  are  present,  the  latter  due  to  mu.s- 


FRACTURES  OF   THE  FEMUR.  397 

cular  relaxation  and  loss  of  control  of  the  lower  fragment.    In  my  case 
the  trochanter  was  prominent  and  eversion  marked. 

Treatment.  The  treatment  is  immobilization  with  traction,  but  pref- 
erably with  more  flexion  of  the  hip  than  is  usual  in  fracture  of  the  neck. 

D.  Fracture  of  the  Great  Trochanter.  Separation  of  the  Apophysis. 

Only  a  few  specimens,  not  more  than  a  dozen,  of  this  injury,  inde- 
pendent of  associated  fracture  of  the  neck,  have  been  reported.  The 
cause  appears  commonly  to  be  a  blow  upon  the  outer  posterior  nortion 
of  the  trochanter ;  occasionally  muscular  action. 

The  fragment  usually  remains  attached  to  the  femur  ^by  tendinous 
and  periosteal  fibres,  and  is  sometimes  broken  into  two  or  more  pieces ; 
it  is  freely  movable  upon  the  shaft,  but  rarely  is  completely  separated 
from  it  and  displaced  upward  or  backward  by  the  attached  muscles. 
Potherat^  reported  a  specimen,  found  in  the  dissecting-room,  with  dis- 
placement upward  of  four  centimetres.  Neck  ^  demonstrated  by  in- 
cision a  flat  fragment  on  the  outer  aspect. 

The  specimens  of  the  separation  of  the  apophysis  are  one  in  Guy's 
Hospital  museum,  Key's  case  (Fig.  277),  one  in  Steeveus's  Hospital,  ^ 
Dublin,  Hilton's,  ^  Ashtou's,  ^  Adami's  "^  and  Daniel's.'^  The  last  four 
are  quoted  fromPoland.  Two  of  these  (Adami's  and  Steevens  Hosp.) 
were  obtained  in  the  dissecting-room  without  history.  In  the  others 
deatii  followed  within  a  few  weeks  after  the  violence  that  was  thought 
to  have  caused  the  separation,  and  was  preceded  by  fever  and  suppura- 
tion about  the  upper  part  of  the  bone.  In 
all  but  one   (Daniels)   the    separation    was  Fjg.  277. 

exactly  along  the  epiphyseal  line,  and  the 
fragment  was  not  displaced ;  it  seems  to  me 
highly  probable  that  they  were  cases  of  osteo- 
myelitis, possibly  originating  in  the  trauma. 

McCarthy's  case  seems  to  me  clearly  to 
be  osteomyelitis  rather  than  fracture. 

Thienhaus  (Annals  of  Surg.,  1906)  dem- 
onstrated an  "  incomplete  separation "  by 
the  x-rays,  but  the  reproduction  is  illegible  ;   ^     ^  ^.        .      .  , 

TT-  /  T-,      ,    ry,     7  r,     !•■■     rn  •  11  •••      Fracture  Or  diastasis  ot  the  greai 

Kruger  {Dent.  Ztschft.  fur  C/nr.,  vol.  Ixxxni.  trochanter.     (Bryant.) 

p.  464)  reports  one. 

Symptoms.  The  symptoms  are  local  pain  on  pressure,  and  mobility 
of  the  fragment  recognizable  if  the  swelling  is  not  too  great.  Most  of 
the  patients  have  been  able  to  walk,  though  with  pain  ;  and  rotation  of 
the  hip  was  painful. 

Treatment.  The  treatment  is  inmiobilization,  preferably  witli  the 
limb  abducted  and  rotated  outward  to  diminish  the  displacing  action 
of  the  attached  muscles.  Local  pressure  by  a  bandage  about  the  hips 
has  been  used,  but  is  probably  unimportant. 

1  Potherat :  Bull,  de  la  Soc.  Anat.,  P'ebrnary,  1888. 

*  Neck  :  Centralblatfc  fiir  Chirurgie,  1903,  p."^1447. 

*  Transactions  Pathological  Society  of  Dublin,  vol.  vii.  n.  S.,  quoted  by  Bennett. 

*  Hilton  :  Ouy's  Hospital  Reports,"  ISfi.'S,  p.  342.         '  Ashton  :  Lancet,  Feb.,  1875,  p.  2.')1. 
°  Poland  :  Traumatic  Separation  of  Epiphyses,  p.  6(j(). 

'  Transactions  London  Pathological  Society,  vol.  xlvii.  p.  174. 


398  FRACTURES. 

E.  Fracture  of  the  Trochanter  Minor. ^ 

More  than  a  score  of  cases  of  this  injury  have  been  reported,  and  as 
most  of  them  have  been  observed  since  1908  and  the  diagnosis  has 
been  made  with  the  .r-rays  it  is  probable  that  the  injury  is  more 
common  than  the  paucity  of  reported  cases  might  imply. 

Only  three  patients  were  adults,  the  others  were  youths  (one  girl) 
between  the  ages  of  eleven  and  seventeen  years.  Of  the  three  adults, 
two — fifty-one  and  eighty-two  years  old — were  injured  in  a  fall  while 
walking;  the  third,  eighty-seven  years,  was  crushed  by  an  autobus; 
the  two  oldest  died  and  the  autopsies  showed  extensive  extravasation 
of  blood  in  the  muscles,  the  adductors  and  psoas  being  specified  in  one. 
One  boy  died  of  septicaemia,  apparently  the  result  of  a  diagnostic 
incision.  A  similar  death  was  briefly  reported  in  1854  by  Brunelle, 
quoted  by  Binet.  In  two  specimens  the  fragment  comprised  a  small 
portion  of  the  shaft  below  the  trochanter.  In  the  young  the  injury 
appears  to  be  separation  of  the  epiphysis,  and  the  fragment  is  dis- 
played upward;  the  large  callus  shown  in  Wagner's  case  suggests  a 
formation  of  bone  by  periosteum  torn  from  the  shaft  below. 

In  all  the  young  patients  the  injury  appears  to  have  been  caused 
by  muscular  action,  usually  in  running,  or  by  sudden  extension  of  the 
thigh  against  resistance,  that  is,  by  the  pull  of  the  psoas-iliacus. 

There  is  sharp  pain  at  the  moment,  and  walking  is  difficult  and 
painful,  perhaps  impossible,  but  one  patient  was  able  to  continue 
at  work  and  did  not  seek  advice  until  after  the  lapse  of  several  days. 
Ludloff  noted  that  the  patient  when  seated  was  unable  to  lift  the  limb 
with  the  knee  straight,  but  Walbaum  found  this  sign  absent  in  one 
case,  and  explained  its  absence  on  the  supposition  that  only  the  psoas 
was  torn  away  and  the  broader  attachment  of  the  iliacus  persisted. 
Eversion  of  the  thigh  was  noted  in  several.  Local  pain  on  pressure 
over  the  trochanter  is  marked;  passive  movements  of  the  limb  are 
unrestricted,  but  active  flexion  (except  in  one)  was  painful  or  impossible. 

The  diagnosis  is  made  on  the  history,  age,  local  tenderness,  and 
painful  active  flexion  of  the  hip,  but  should  be  confirmed  by  the  .r-raj^s. 

Recovery  has  been  rapid  and  complete  with  the  aid  of  rest  in  bed  with 
the  limb  supported  in  partial  flexion  at  the  hip  and  knee. 

2.  FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 

The  highest  of  the  fractures  considered  in  this  section  are  the  sub- 
trochanteric, the  lowest  the  supracondyloid;  intercondyloid  or  T-frac- 
tures  will  be  described  in  the  following  section.  Exceptional  and 
irregular  forms  are  occasionally  seen,  spiral  and  oblique  fractures  in 

1  Julliard,  Progr^s  Med.,  1879,  vii,  825;  Hutchinson,  Brit.  Med.  Journal,  1893,  ii,  671; 
Bennett,  ibid.,  1895,  ii,  893;  Piquand  and  Douai,  Bull.  Soc.  Anat.,  1908,  Ixxxiii,  486; 
Chaput,  Bull.  Soc.  de  Chir.,  1909,  xxxv,  207;  Hoch,  Deutsche  Ztschft.  fur  Chir.,  xcvii,  405; 
Feiner,  ibid.,  vol.  xcix,  453;  Pochhammer,  Arch,  fiir  klin.  Chir.,  vol.  xci,  719;  Bilhr, 
Deutsche  med.  Wochenschrift,  1911,  No.  42,  p.  1942;  Binet  and  Hamant,  Rev.  de  Cliir., 
1911,  xliii,  p.  564;  Bardenheuer  and  Hannenmuller,  quoted  by  Binet;  Blenker,  Ztsclift. 
f.  Orthop.  Chir.,  vol.  xxix;  Noegeli,  Beitriige  zur  klin.  Chir.,  vol.  Ixxvii,  p.  242;  Vorschiitz, 
Deutsche  Ztschft.  f.  Chir.,  vol.  cxvii,  p.  243;  Wagner,  idem,  vol.  cxix,  p.  557;  Walbaum, 
idem,  1914,  vol.  exxviii,  p.  139;  Metcalf,  Jour.  Am.  Med.  Ass.,  1915,  p.  1234. 


FRACTURES  OF   THE  FEMUR. 


399 


which  the  main  Hne  or  a  fissure  passes  from  the  upper  part  of  the  shaft 
to  the  neck  and  the  trochanter,  and  even  in  which  the  upper  fragment 
has  been  spHt  kmgitudinally  through  the  trochanter. 

Causes.  The  causes  of  fracture  are  direct  and  indirect  \'iolence  and 
muscuhxr  action;  see  Chapter  III. 

Pathology.  All  the  varieties  of  fracture  that  may  occur  in  long  bones 
are  met  with  in  the  femur,  but  in  the  great  majority  of  cases  the  frac- 
ture is  oblique  and  often  extremely  so,  the  obliquity  usually  correspond- 
ing to  the  normal  curves  of  the  bone ;  that  is,  in  the  middle  part  of  the 
bone  it  runs  from  behind  forward  and  downward,  and  in  the  upper 
third  forward  and  outward.  Transverse  fracture  is  rare  in  adults,  but 
more  common  in  children. 


Fig.  278. 


Fig.  279. 


Fracture  of  the  upper  third  of  the  femur;  union 
with  great  displacement.     (A.  Cooper.) 


Transverse  fracture  of  the  femur. 

(GURLT.) 


The  displacement  is  marked,  and  is  the  effect  of  the  fracturing  cause, 
of  the  contraction  of  the  powerful  muscles  of  the  thigh,  and  of  the 
swelling  of  the  limb  beneath  the  fascia  by  which  it  is  broadened  and 
shortened.  The  lower  fragment  usually  passes  behind  and  to  the  iimer 
side  of  the  upper  one  and  is  sometimes  rotated  outwardly;  in  addition 
there  is  angular  displacement,  the  angle  usually  being  directed  forward 
or  forward  and  outward,  but  sometimes  backward  or  inward. 

Inclination  forward  and  outward  of  the  lower  end  of  the  upper  frag- 
ment after  fracture  in  the  upper  third  is  the  rule  and  is  mainly  due 
to  muscular  action,  the  contraction  of  the  gluteal  nuiscles  and  the 
psoas  upon  the  upper  fragment  and  of  the  adductors  and  the  flexors  of 
the  leg  upon  the  lower  one.  The  tendency  of  the  former  is  to  tilt  the 
upper  fragment  forward,  outward,  or  in  both  directions;  that  of  the 


400 


FRACTURES. 


latter  is  to  draw  the  lower  fragment  up  against  the  upper  one,  and  this 
will  produce  an  angular  displacement  in  any  direction  that  is  favored 
by  the  line  of  fracture.  The  fact  that  the  displacement  is  sometimes 
backward  or  inward  does  not  disprove  the  influence  of  the  muscles 
attached  to  the  upper  fragment,  as  has  been  argued;  the  principal 
agency  is  the  drawing  upward  of  the  lower  fragment,  and  if  the  frag- 
ments are  so  related  at  the  seat  of  fracture  that  the  upper  one  is  pushed 
in  a  different  direction  from  that  in  which  its  muscles  would  draw  it  the 
latter  must  yield.  In  the  extreme  case  shown  in  Fig.  278  it  can  be 
seen  how  great  the  angular  displacement  and  at  the  same  time  the 
overriding  can  be  under  these  circumstances.  The  angulai  displace- 
ment necessarily  produces  shortening,  and  this  shortening  varies  accord- 
ing to  the  angle,  and,  the  angle  being  the  same,  according  to  the  distance 
of  the  fracture  below  the  neck  of  the  bone  in  the  upper  half.  In  the  same 
specimen  outer  rotation  of  the  lower  fragment  is  also  very  marked.  In 
transverse  and  toothed  fractures,  displacement  may  be  lateral  or  angular 

or  both,  and  if  the  lateral  displace- 
^^''■-  ^^^"  ment  is  sufficient  to  free  the  frag- 

ments they  may  override. 

Extreme  obliquity  of  the  frac- 
ture, which  is  not  uncommon, 
leads  occasionally  to  a  complica- 
tion which  may  be  very  trouble- 
some and  may  transform  a  simple 
fracture  into  a  compound  one,  the 
penetration  of  the  muscle  and 
sometimes  of  the  skin  by  the 
sharp  end  of  the  upper  fragment. 
This  is  specially  likely  to  occur 
in  fractures  of  the  lower  third, 
the  sharp  lower  end  of  the  upper 
fragment  perforating  the  quad- 
riceps or  even  the  skin.  The 
perforation  of  the  muscle  is  di- 
rected downward  as  well  as  for- 
ward, probably  because  the  knee 
is  flexed  at  the  moment  when  it 
occurs,  and  then  when  the  joint 
is  straightened  the  muscle  retracts 
upward  along  the  spike  of  bone; 
this  makes  it  necessary  to  ilex 
the  knee  again  in  order  to  free 
the  bone,  thus  drawing  the  mus- 
cle down  past  its  end.  In  these 
fractures  of  the  lower  third  the 
lower  fragment  is  sometimes 
tilted  (presumably  by  the  action 
of  the  gastrocnemius)  so  that  its 
upper  end  is  directed  obliquely  backward,  and  it  is  sometimes  split  by 
a  line  of  fracture  running  between  the  condyles.  (See  Intercondy- 
loid  Fractures.J 


Fracture  of  left  femur  close  below  trochanters. 


FRACTURES  OF   THE  FEMUR. 


401 


Fig.  281. 


Other  complications  are  rare,  the  ^•essels  and  nerves  not  lying  in 
sufficiently  close  relation  with  the  bone  to  be  often  injured.  ^Miiller^ 
reported  a  case  of  rupture  of  the  inner  and  middle  coats  of  the  femoral 
artery  in  a  fracture  at  the  junction  of  the  middle  and  lower  thirds; 
gangrene  threatening,  amputation  was  done;  death.  And  Selenkow- 
reported  one  of  laceration  of  the  femoral  vein;  death  followed,  appar- 
ently the  result  of  officious  treatment.  The  danger  is  greater  in  the 
lower  third  than  elsewhere,  and  pressure  upon  the  vessels  wlicn  they 
are  not  torn  may  cause  gangrene  of  the  leg 
either  by  its  continuance  or  by  the  formation 
of  a  thrombus  in  consequence  of  the  bruising. 

Fissures  extending  upward  and  downward 
from  the  seat  of  fracture  are  probably  not  in- 
frequent, especially  in  gunshot  fractures. 

Double  fractures  have  been  observed,  and, 
according  to  Malgaigne,  there  is  a  specimen  of 
triple  fracture  in  the  Musee  Dupuytren.  Double 
fracture  should  always  be  looked  for  when  the 
causative  violence  has  been  great.  Commin- 
uted or  splintered  fractures  are  not  uncommon, 
especially  among  fractures  by  direct  violence, 
and  the  splinters  may  be  large. 

The  effusion  into  the  knee-joint  which  is 
observed  so  frequently  in  the  course  of  fractures 
of  the  thigh  has  received  particular  attention 
since  1870,  when  Rouge,  of  I^ausaunc,  first 
wrote  concerning  it.  Among  those  who  have 
studied  it  most  carefully  are  Gosselin,^  Berger,* 
Marjolin,  Alison,^  and  Hennequin,^  the  two 
former  attributing  it  to  the  passage  of  extra- 
vasated  blood  into  the  joint,  the  third  and 
fourth  to  interference  with  the  return  venous  cir- 
culation, and  the  last,  in  common  w4th  Verueuil 
aud   others,  to  an   associated   sin-ain.       Otliers      Fracture  of  the  neck  of  the 

1  1  j_    j_i  /•    ,1  II-     •  femtir  and  of  the  shaft.     A 

agam  have  souglit  the^  cause  of  the  ettusions  spH^ter,  5  inches  long  and 
noted  in  the  later  periods  of  the  case  in  the  nearly  i  inch  wide,  composed 
])rolonged  immobihty  and   the  extended  posi-   of  the  cortical  layer,  has  been 

^.  '^ .  •    I  1  rf»     •  •  turned    completely  about   lis 

tiou.  An  appreciable  eltusiou  makes  its  ap-  long  axis  and  become  united, 
])carauce  in  a  majority  of  the  cases  within  the    »^ith  its  original    periosteal 

i-  ,  1    . 1  1  (•11        •         J.1       •    •  'j.  -  i    surface  in  contact   with    the 

first  three  days  following  the  mjury  ;    it  is  most    ^ther  fragments.    (Figured  by 

prompt  in  children  aud  when  the  fracture  is  in  guki.t  from  the  Museum  of 
the  lower  third,  and  is  more  common  after  the  Royal  College  of  Surgeons, 
fracture  by  iudirect  than  after  fracture  1)3' direct 

violence.  It  disappears  ]:)roin[)tly  in  children,  more  slowly  in  adults, 
and  may  persist  for  years. 


'  Miiller:   Deutsche  mecl.   Wochenschrift,   October  11,    1888. 
2  Selenkow:  St.  Petersburg  med.  Woch.,  October  S,   1888. 

'  Gosselin:  Clinique  de  rHopital  de  la  Charite.  '  Merger:  Th^sc  de  Pari.s,  1873. 

^  Alison:   Th^se  de  Pari.s. 

''  Honncquin:  Loc.  cit.,  p.  78.     (See  also  the  discu.ssiona  in  the  Bulletins  de  la  Societe 
de  Chirurgie,  1878,  pp.  G  and  336.) 


402 


FRACTURES. 


Symptoms.  The  symptoms  are  pain,  loss  of  function,  abnormal 
mobility,  deformity,  and  crepitus.  As  the  bone  is  deeply  placed  under 
thick  muscles,  irregularity  in  its  outline  cannot  be  recognized  by  the 
touch;  angular  displacement  can  often  be  readily  recognized  in  thin 
patients  by  the  eye,  but  the  method  of  examination  which  renders  the 
best  service  in  this  respect  is  the  comparative  measurement  of  the  two 
limbs.  The  fixed  points  commonly  used  for  this  purpose  are  the  ante- 
rior superior  spinous  process  of  the  ilium  and  the  tip  of  the  external 
malleolus;  the  rules  for  making  these  measurements  and  the  precau- 
tions to  be  taken  to  guard  against  error  have  been  given  in  Chapter 
IV  and  in  the  preceding  section  of  this  chapter,  page  382;  the  capi- 
tal point  is  to  make  sure  that  the  two  limbs  form  the  same  angle  with 
the  pelvis,  and  the  best  method  of  doing  this  is  to  stretch  a  tape  across 


Fig.  282. 


Fig.  283. 


Oblique  fracture  of  shaft  of  femur;   rear 
view. 


Oblique  fracture  uf  the  shaft;  front  view. 
(U.  S.  Army  Med.  Museum.) 


the  abdomen  from  one  anterior  superior  iliac  spine  to  the  other,  and 
a  second  one  at  right  angles  to  the  first  from  its  centre  downward, 
and  then  to  place  the  ankles  at  equal  distances  from  the  second  line. 
The  shortening  may  vary  from  a  small  fraction  of  an  inch  to 
several  inches. 


FRACTURES  OF   THE  FEMUR. 


403 


Abnormal  mobility  may  be  recognized  by  placing  the  hand  under 
the  thigh  at  the  suspected  seat  of  fracture  and  gently  lifting  it,  or 
by  holding  the  upper  portion  of  the  thigh  down  with  one  hand  and 
gently  lifting  the  leg  or  moving  it  from  side  to  side  with  the  other,  or 
by  observing  whether  the  great  trochanter  moves  with  the  leg  when 
the  latter  is  gently  rotated.  The  examination  for  abnormal  mobility 
and  crepitus  should  be  made  very  gently,  and  should  not  be  prolonged 
if  the  latter  is  not  promptly  obtained. 

Prognosis.  Any  fracture  of  the  femur  is  a  serious  injury  to  this 
extent,  that  its  proper  treatment  makes  confinement  to  the  bed  for 
several  weeks  desirable,  that  it  will  make  it  difficult  for  a  long  time 
for  the  patient  to  get  about  even  with  crutches,  and  that  it  may  lead 
to  shortening  of  the  limb,  even  if  not  to  a  persistent  limp.     It  also 

Fig.  284. 


Fracture  of  the  shaft,  of  the  femur. 


exposes  to  the  possibility  of  a  fatal  result,  especially  in  the  aged  and 
alcoholic,  and  to  that  of  gangrene  of  the  limb  by  rupture  or  bruising 
of  the  main  vessels  or  by  pressure  upon  them. 

A  simple  fracture  without  displacement,  or  suitably  reduced,  will 
usually  consolidate  in  six  or  seven  weeks  sufficiently  to  allow  the 
patient  to  get  about  on  crutches,  and  he  will  be  able  to  bear  his  weight 
safely  upon  the  limb,  and  to  discard  the  crutches  in  three  or  foiu'  weeks 
more.  In  exceptioual  cases  the  consolidation  may  be  delayed,  and  it 
happens  occasionally  that  a  secondary  fracture  occurs  soon  after  the 
patient  first  leaves  his  bed,  usually  in  consequence  of  a  fall. 

Most  authorities  assert  that  an  oblique  fracture  of  the  shaft  of  tlie 
femur  cannot  be  cured  without  some  permanent  shortening.  Since  the 
time  of  Desault  the  possibility  of  a  better  result  has  been  claimed  by 
different  surgeons,  and  for  different  dressings,  but  no  method  has  yet 
won  a  general  acceptance  of  its  claim.  While  there  is  no  reason  to 
doubt  the  possibility  of  a  union  without  shortening,  and  while  I  believe 
such  union  has  been  obtained  in  many  cases,  I  do  not  believe  there  is 
any  method  of  treatment  which  can  be  depended  upon  to  secure  it  in 
any  given  case,  for  it  can  never  be  known  in  advance  whether  or  not 
the  patient  will  be  able  or  tractable  enough  to  support  tlie  traction  and 
pressure  necessary  to  success.  Some  surgeons  have  claiuied  nn  actual 
elongation  of  the  limb  by  the  use  of  continuous  tractiou.  Although  a 
certain  doubt  is  thrown  over  such  assertions  by  the  acknowledged  ddli- 


404  FRACTURES. 

culty  of  making  accurate  measurements,  and  by  the  possibility  of  a 
previously  existing  inequality  in  the  length  of  the  limbs,  the  occur- 
rence is  not  impossible,  however  improbable  it  may  be. 

The  best  series  of  results  of  which  I  have  knowledge  are  those  of 
Bardenheuer  published  by  Luxembourg.*  Of  179  successive  cases 
treated  in  hospital,  1902-06,  157  recovered  without  shortening,  in  15 
the  shortening  was  less  than  1  inch,  and  in  7  between  1  and  1 J  inches. 
Ashhurstand  XewelP  found  in  17  of  the  shaft  (excluding  subtrochan- 
teric and  supra-condylar)  5  without  shortening,  and  shortening  of  one 
centimeter  in  8  and  two  in  4. 

The  persistence  of  some  shortening,  even  an  inch,  does  not  necessarily 
cause  the  patient  to  limp,  since  it  may  be  compensated  for  by  an  inclina- 
tion of  the  pelvis.  The  rigidity  in  the  knee  is  likely  to  persist  for  a  length 
of  time  that  is  greater  if  the  patient  is  older  and  of  rheumatic  habit. 

The  prognosis  in  compound  fractures  is  particularly  grave  when  the 
injury  has  been  produced  by  direct  violence ;  and  in  a  fracture  of  both 
thighs,  particularly  if  either  is  compound,  the  shock  is  usually  so  great 
as  to  put  the  patient's  life  in  serious  danger. 

Treatment.  The  dressings  now  in  use  for  the  treatment  of  fracture 
of  the  shaft  of  the  femur  are  Buck's  extension,  Hodgen's  suspended 
splint,  combined  suspension  and  traction,  the  long  side-splint  or  the 
hip-splint,  usually  with  traction,  encasement  in  plaster  of  Paris,  and 
the  double  inclined  plane.  All  have  been  described  in  detail  in  Chap- 
ter VII.  It  remains  only  to  note  their  special  advantages  and  indi- 
cations. 

The  long  side-splint  without  traction  should  be  used  only  as 
a  temporary  dressing  during  transport  or  for  a  few  days  at  first  when 
the  condition  of  the  patient — delirium,  shock,  associated  injuries — con- 
traindicates  one  which  would  not  be  sufficiently  restraining,  or  the 
application  of  which  would  be  too  exhausting. 

The  long  side-splixt  with  traction  may  be  used  temporarily 
later  in  the  case  if  the  patient  is  to  be  transported  to  a  distance ;  it  is 
cheaper  than  a  hip-splint,  can  be  readily  improvised,  and  as  it  extends 
almost  to  the  axilla  it  ensiu-es  greater  immobilization.  (See  also  Blake's 
splint,  Fig.  289.) 

"Buck's  extension"  (Fig.  56)  is  suitable  for  the  majority  of  cases, 
is  easily  borne,  and,  as  it  permits  a  certain  freedom  of  motion,  promotes 
the  comfort  and  well-being  of  the  patient.  It  also  permits  constant 
supervision  of  the  fracture  and  easy  recognition  of  shortening  or 
angular  displacement.  The  occasional  outward  rotation  of  the  upper 
fragment  by  gravity  or  by  the  turning  of  the  patient  in  bed  can  be 
measurably  met  by  a  small  firm  cushion  behind  the  trochanter.  In 
the  higher  fractiu-es,  with  the  usual  flexion  and  abduction  of  the  upper 
fragment,  it  is  inadequate. 

Hodgen's  suspexded  splixt  (Fig.  59)  gives  even  greater  comfort 
and  freedom,  permits  greater  variety  in  the  attitude  given  to  the  limb 

1  Luxembourg:   Deutsche  Zeitschrift  fur  Thir.,  1908.  vnl.  94.  p.  387. 

2  Ashhurst  and  Newell:  Annals  of  Surg.,  1908,  vol.  48,  p.  754. 


FRACTURES  OF   THE  FEMUR. 


405 


— abduction  and  flexion  for  the  higher  fractures — and  allows  the  knee 
to  be  kept  partly  flexed,  an  easier  position.  It  is  specially  advan- 
tageous in  the  older  and  feebler  patients.    I  do  not  think  it  immobilizes 


Fig.  285. 


Makins  forcible  traction  in  fracture  of  the  femur. 


the  fractures  quite  so  well  as  Buck's  extension  does,  but  I  have  found 
no   serious   inconvenience  from   this  and   I  use   the  splint  more  and 


Fig.  286. 


Hodgen  splint  with  independent  traction. 

more  in  preference  even  to  Buck's,  and  alwa>s  in  high  fractures  and 
in  those  of  the  lower  third;  in  the  latter  Ijccause  of  the  flexion  of 
the  knee. 
■29 


406  FRACTURES. 

Combined  suspension  and  traction  (Figs.  272,  286),  I  can  recom- 
mend after  long  use  as  preferable  to  Buck's  or  Hodgen's.  Less  traction 
is  needed  than  in  Buck's,  and  it  can  be  more  exactly  determined  and 
maintained  than  by  Hodgen's,  and  the  patient's  comfort  is  much 
greater  than  with  Buck's.  In  addition,  lateral  pressure  to  oppose 
angular  or  lateral  displacement  can  be  readily  made  by  the  upper 
supporting  bands.  I  was  glad  to  see  it  in  routine  use  and  warmly 
praised  in  several  large  military  hospitals  in  France  this  year  (1916). 
(Fig.  286). 

Steinmann's  method  of  making  traction  by  a  weight  attached  to  a 
pin  driven  through  the  condyles  has  been  described  in  Chapter  VII. 

Encasement  in  plaster  of  paris,  including  the  pelvis,  after 
having  been  widely  used  as  the  preferred  treatment  for  some  years 
after  1870,  has  now  largely  given  place  to  continuous  traction  during 
the  first  month  or  six  weeks,  but  is  still  much  used  in  the  later  stages 
when  displacements  are  no  longer  to  be  much  feared  and  the  patient 
needs  only  to  be  protected  against  accident  while  he  goes  about  on 
crutches  and  awaits  complete  consolidation.  In  case  of  delayed  union 
it  may  even  permit  the  patient  to  bear  part  of  his  weight  upon  the 
limb  and  thus  hasten  ossification  of  the  bond.  It  is  still  sometimes 
used  from  the  beginning,  and  the  patient  allowed  to  go  about  on 
crutches,  but  marked  displacement  can  occur  under  such  circumstances 
and  the  chance,  in  my  opinion,  should  not  be  taken.  The  absence  of 
a  fixed  upper  point  of  support  makes  it  easy  for  overriding  and  angular 
displacement  to  occur. 

From  time  to  time  the  suggestion  is  renewed  of  a  splint  or  dressing 
which  will  permit  the  patient  to  leave  the  bed  almost  immediately 
after  the  accident.  To  my  mind  not  only  are  the  alleged  advantages 
unimportant  or  even  illusory,  but  the  possible  disadvantages  arising 
from  the  lack  of  efficient  control  of  the  fragments  are  in  most  cases 
so  great  and  so  threatening  as  to  outweigh  the  claimed  advantages 
even  if  they  were  much  greater  than  I  deem  them  to  be.  If  the  usual 
traction  is  needed  to  maintain  length,  as  is  habitually  the  case,  it  must 
be  furnished  in  an  ambulatory  dressing  either  by  the  weight  of  the 
limb,  which  acts  only  while  the  patient  is  upright,  or  by  direct  pressure 
upon  the  skin  covering  bony  points,  and  abundant  experience  has 
shown  that  such  pressure  if  efi^ective  cannot  be  borne. 

The  latest  example  is  Delbet's  splint  which  seems  likely  to  have  a 
full  trial  in  the  French  military  hospitals.  It  consists  of  three  sets  of 
steel  rods  and  spiral  springs  attached  above  to  a  ring  about  the  hip 
taking  its  bearing  upon  the  perineum,  and  below  to  a  collar  above  the 
knee  reinforced  by  a  gypsum  case  or  splints  extending  to  the  foot. 
Some  excellent  results  have  been  reported,  notably  by  Alquier^  at 
Chalons,  but  he  impressed  me  as  a  man  exceptionally  well  fitted  to 
treat  fractures,  one  who  with  any  appliance  would  obtain  better  results 
than  most.  He  himself  told  me  he  could  escape  sloughs  only  by  keeping 
his  patients  out  of  bed.    I  saw  in  Delbet's  wards  three  patients  wearing 

1  Alquier  :  Bull.  Soc.  de  Chir.,  1916,  p.  985. 


FRACTURES  OF   THE  FEMUR. 


407 


the  splint  with  shortenings  of  from  2  to  3|  inches,  and  I  heard  unfa^'o^- 
able  opinions  expressed  by  several  surgeons.  Unless  and  until  over- 
thrown by  sufficient  experience  I  must  deem  the  principle  of  the  splint 
fundamentally  wrong.  For  a  reference  to  Dollinger's  dressing  see 
page  120. 

The  hip-splint,  in  any  of  its  various  forms,  meets  the  same  indica- 
tions more  conveniently,  though  more  expensively,  and  as  it  can  be 
combined  with  traction  (as  in  hip- joint  disease)  it  can  be  safely  used  at 
an  earlier  period  in  the  case.  It  is  especially  convenient  in  cases  of 
delayed  union,  for  it  relieves  the  patient  from  confinement  to  bed. 

Fig.  287. 


Anterior  suspended  splint,  without  traction,  in  compound  fracture. 

The  double  inclined  plane  (Fig.  62)  is  occasionally  useful  as  a 
temporary  dressing  in  very  severe  injuries  when  the  swelling  is  great 
or  the  circulation  embarrassed;  also  in  compound  fractures  with  so 
much  loss  of  bone  that  traction  is  not  required  to  prevent  overriding. 

The  same  indications  can  be  met  by  a  long  anterior  splini  flexed  at 
the  knee  and  suspended  from  a  horizontal  bar  placed  a  short  distance 
above  it  (Fig.  287).  Such  a  splint  can  be  conveniently  made  of  a 
stout  iron  rod,  like  Smith's  splint  (Fig.  43),  but  it  is  better  to  have 
the  leg  horizontal;  it  permits  an  easy  change  of  the  dressings  of  the 
wound  without  disturbing  the  fragments,  but,  like  the  inclined  plane, 
it  needs  constant  watchfulness  to  maintain  the  traction  needed  to 
keep   the   fragments   in   position. 

In  fractures  of  the  upper  third  the  thigh  should  be  flexed  and 
abducted  in  order  that  the  lower  fragment  shall  be  in  line  with  the 
upper  one  which  usually  assumes  this  attitude,  and  for  this  the  Hodgen 
splint  is  the  most  convenient. 

In  some  fresh  cases  forcible  traction  may  be  needed,  either  to  over- 
come overriding  or  to  permit  correction  of  lateral  displacement  in 
transverse  fracture.  It  may  conveniently  be  made  as  shown  in  Fig. 
285.  In  older  cases,  when  the  overriding  has  been  partl>'  flxed  !)>■ 
changes  in  the  soft  parts,  prolonged  forcible  traction  by  Steinmann's 
device  may  be  used,  or  very  forcible  temporary  traction  by  powerful 
instruments  devised  for  the  purpose. 


408 


FRACTURES. 


After  five  or  six  weeks,  in  most  cases,  abnormal  mobility  will  have 
disappeared  or  so  far  diminished  that  traction  is  no  longer  needed ; 
angular  displacement  is  then  the  only  one  that  is  likely  to  take  place, 
and  this  can  be  prevented  by  plaster-of-Paris  encasement.  If  the 
abnormal  mobility  has  wholly  disappeared  I  usually  remove  the  appa- 
ratus and  keep  the  patient  in  bed  for  a  few  days  without  any  dressing ; 
then  I  apply  a  plaster  dressing,  including  the  pelvis  if  the  fracture  is 
above  the  lower  third,  and  allow  him  to  go  about  on  crutches.  After 
another  fortnight  the  plaster  is  removed. 

In  young  children  vertical  suspension  is  by  far  the  most  convenient 
and  satisfactory  method  of  treatment.  Strips  of  adhesive  plaster  are 
applied,  as  in  Buck's  extension,  to  both  legs  and  attached  by  cords  to 
a  support  immediately  above  the  child  so  that  the  pelvis  rests  lightly 
upon  the  bed  (Fig.  288).  I  have  sometimes  made  this  attachment 
elastic  by  introducing  a  rubber  cord  or  by  using  a  support  with  a  flex- 
ible arm,  but  have  found  no  great  advantage  in  it  and  some  disadvan- 
-tage  because  of  the  gradual  yielding.     The  fixed  support  is  also  better 


Fig.  288. 

m 

^B 

\ 

1 

Ipp'^^^g 

^^r 

"^^^•^ 

9 

^^^P 1 '  ^^"  ^M 

■ 

■rW  |i 

Fracture  of  the  thigh;  vertical  suspension.     The  fracture  i:?  compound  in  the  patioiit  on  the 


right 

than  the  weight  and  pulley  which  are  sometimes  used.  The  position  is 
well  borne  and  makes  it  easy  to  keep  the  child  dry  and  clean.  The 
contact  with  the  bed  should  be  so  light  that  the  hand  can  be  passed 
easily  under  the  pelvis.  In  very  young  children  it  is  sometimes  suffi- 
cient to  bind  the  flexed  thigh  to  the  abdomen. 

Dr.  A.  W.  Mitchell  devised  a  splint  which  permits  the  child  to  be 
carried  about.  It  consists  of  three  wooden  splints — body,  leg,  and 
thigh  pieces — fastened  together  by  thumb-screws  for  angular  adjust- 
ment. Traction  is  made  by  having  the  thigh  ])iece  project  beyond  the 
flexed  knee,  so  that  the  bandage  about  the  upper  part  of  the  leg  will 
draw  it  downward. 


FRACTURES  OF   THE  FEMUR.  409 

In  older  children — over  ten  years — I  have  found  Buck's  extension 
the  best,  and  decidedly  preferable  to  the  double  side-splint,  with  which 
it  is  difficult  to  prevent  shortening  and  angular  displacement.  Fairly 
firm  union  may  usually  be  expected  in  three  weeks. 

In  fractures  of  the  lower  third  the  engagement  of  the  lower  end  of 
the  upper  fragment  in  the  quadriceps,  or  even  in  the  overlying  skin, 
adds  greatly  to  the  difficulty  of  reduction.  This  can  sometimes  be 
made  by  flexing  the  hip  and  the  knee  to  a  right  angle,  thus  drawing 
the  muscles  downward  along  the  penetrating  fragment,  and  then  com- 
])leting  the  disengagement  by  strong  traction  in  the  axis  of  the  shaft, 
the  flexion  being  maintained.  If  this  fails  the  skin  and  fascia  must 
be  freely  incised  over  the  end  of  the  fragment  and  the  bone  disengaged 
by  direct  manipulation.  If  the  point  of  the  bone  has  perforated  the 
skin  the  opening  should  be  enlarged,  both  to  facilitate  the  disengage- 
ment and  to  evacuate  the  extravasated  blood.  The  Hodgen  splint 
should  be  preferred  in  the  treatment  of  these  fractures,  for  it  permits 
moderate  flexion  of  the  knee  and  thus  tends  to  avoid  the  tilting  of  the 
lower  fragment  which  may  happen  when  the  knee  is  kept  extended. 

If  the  artery  is  torn  it  may  be  tied  in  the  wound  ;  if  the  vein  alone 
is  torn  it  may  be  tied,  or,  if  not  torn  entirely  across,  the  deep  soft  parts 
may  be  sutured  over  it  so  as  to  oppose  escape  of  the  blood,  and  the 
attempt  made  to  save  the  limb,  but  if  gangrene  appears  amjnitation 
must  be  done  at  once.  Division  of  both  artery  and  vein  justifies  im- 
mediate amputation. 

In  compound  fractures,  if  the  fragments  come  readily  into  place  and 
show  but  little  tendency  to  important  displacements,  the  Hodgen  splint, 
with  or  without  additional  traction,  according  to  need,  is  con\'enient, 
for  it  permits  the  wound  to  be  dressed  without  disturbance  of  the  frag- 
ments. In  more  difficult  cases  heavy  plaster  splints  and  encasements 
embracing  the  pelvis  (Fig.  69)  may  better  secure  retention,  and 
additional  and  very  serviceable  temporary  fixation  may  be  got  by  a 
Lane  plate,  to  be  removed  through  the  wound  after  two  or  three  weeks. 
Of  course,  if  the  wound  is  suitable  for  immediate  closure  the  plate 
may  be  left  in  permanently. 

Fig.  289. 


Blake  splint  for  early  transport. 


A  convenient  device  to  permit  the  temporary  interruption  of  treat- 
ment by  suspension  and  traction  for  the  purpose  either  of  dressing  the 
wound  or  transporting  the  patient  is  found   in  Dr.    Blake's'   si)lint 

1  Bhike:  Bull,  de  la  Soc.  de  Chir.,  1915,  p.  11S5. 


410  FRACTURES. 

(Fig.  290).  The  side  rods  are  connected  at  the  upper  end  by  a  posterior 
rod  which  takes  its  bearing  against  the  tuberosity  of  the  ischium. 
The  length  of  the  hmb  is  maintained  by  fastening  the  traction  bands 
to  the  lower  end  of  the  splint,  the  latter  being  drawn  upon  by  the 
weight.  A  modification  shown  in  Fig.  289  is  intended  for  early  trans- 
port of  the  patient,  especially  in  military  surgery. 

Fig.  290. 


The  Blake  splint. 


Delayed  union,  if  the  fragments  are  in  a  fairly  good  position  and 
their  mobility  is  not  great,  is  best  treated  ordinarily  by  plaster-of -Paris 
encasement,  including  the  pelvis,  and  by  bearing  some  weight  upon  the 
limb  with  the  support  of  crutches.  I  have  seen  union  become  solid  as 
late  as  the  sixth  month. 

In  failure  of  union,  when  the  position  of  the  fragments  is  bad  and 
the  mobility  marked  after  three  or  four  months,  resection  of  the  ends 
and  readjustment  are  required.  I  have  always  made  the  incision  on 
the  outer  side,  cut  the  ends  square,  and  kept  them  in  contact  by  a 
suspended  splint  or  by  resting  the  limb  upon  an  inclined  support  so 
that  the  leg  and  lower  fragment  would  constantly  press  do^A^lward 
toward  the  upper  one.  Occasionally  I  have  used  plaster  of  Paris  over 
the  primary  dressing  of  the  wound.  For  other  details  and  methods 
see  Chapter  VIII. 

3.  FRACTURES  AT  THE  LOWER  END  OF  THE  FEMUR. 

In  this  group  are  here  included  intercondyloid  fractures,  separation 
of  the  lower  epiphysis,  and  fracture  of  either  condyle. 

A.  Intercondyloid  Fractures. 

In  these  fractures  both  condyles  are  separated  from  the  shaft  and 
from  each  other,  the  line  being  T-shaped  or  A^-shaped.  The  fracture 
is  sometimes  cla.ssed  as  a  snpracondyloid  fracture  with  splitting  of  the 
lower  fragment,  since  that  is  thought  to  be  the  mode  of  production  in 
most  cases  ;  the  shaft  is  first  broken  and  then  the  upper  fragment  pene- 
trates and  splits  the  lower  (Fig.  292).  The  claim  that  the  fracture  is 
caused  by  a  violence  transmitted  through  the  ])atella  which  acts  as  a 
wedge  and  splits  off  the  condyles  does  not  bear  the  test  of  experiment 
or  harmonize  with  the  fact  that  in  a  fall   the  blow  is  rarely  received 


FRACTURES  OF  THE  FEMUR. 


411 


upon  the  patella.  Trelat/  in  an  elaborate  article  in  whicli  it  was  first 
sought  to  give  a  detailed  and  full  account  of  fracture  of  the  lower  end 
of  the  femur,  points  out  that  in  six  cases  of  supracondyloid  fracture 
the  average  age  was  twenty-seven  and  a  half  years,  while  in  thirteen 
cases  of  intercondyloid  fracture  it  was  forty-eight  and  a  half  years. 
The  number  of  cases  seems  to  me  too  small  to  warrant  the  inference 
that  the  difference  is  an  essential  and  constant  one. 

The  main  line  of  fracture  across  the  shaft  may  be  very  oblique,  as 
in  the  common  fracture  of  the  lower  third,  but  is  usually  more  nearly 
transverse  in  its  general  direction  with  splintering  which  makes  the 
surface  irregular,  and  lies  close  to  the  base  of  the  condyles. 

The  line  between  the  condyles  follows  the  intercondyloid  notch,  and 
is  vertical  and  antero-posterior.  In  a  case  observed  by  Nelaton  and 
reported  by  Trelat  (loc.  cit.,  p.  73),  the  mechanism  of  the  separation  of 
the  condyles  is  shown  plainly,  the  upper  fragment  being  impacted  into 
the  lower  one,  but  mainly  on  the  inner  side,  and  the  separation  of  the 
condyles  merely  a  fissure  (Fig.  293).  Usually,  however,  the  condyles 
are  completely  detached  from  each  other  and  sometimes  separated  far 
enough  to  allow  the  patella  to  sink  in  between  them,  and  either  may  be 
further  displaced  backward  than  the  other,  with  a  corresponding  rota- 
tion of  the  leg,  since  the  tibia  retains  its  connection  with  them.  The 
crucial  ligaments  may  be  torn  longitudinally  or  transversely,  and  then 
the  attachment  of  the  tibia  is  less  close. 


Fig.  291. 


Fig.  292. 


Intercondyloid  fracture  of  the  femur. 
(Bryant.) 


Comminuted  fracture  of  the  femur,  with 
splitting  of  the  condyles.    (Gurlt.) 


The  injury  is  frequently  compound,  from  within  outward  l)y  tlu>  end 
of  the  upper  fragment,  especially  when  the  fracture  is  oblicjue;  danger- 
ous pressure  by  one  or  the  other  fragment  upon  the  popliteal  vessels  is 
not  uncommon,  and  the  vein  and  artery  have  been  torn,  the  vein  the 


1  Trelat.  Archives  Generales  de  Med.,  1854,  vol.  ii,  p.  59. 


412 


FRACTURES. 


Fig.  293. 


more  frequently.  In  one  of  my  cases — fracture  of  both  femurs  by  a 
fall  of  forty  feet,  the  patient  dying  in  thirty-six  hours — one  fracture 
was  compound  by  perforation  of  the  muscle  and  skin  in  front  by  the 
upper  fragment,  the  other  was  simple,  but  the  popliteal  vein  was  torn, 
and  there  was  a  large  extravasation  of  blood  in  the  thigh.  In  each 
the  lower  end  of  the  upper  fragment  was  very  irregular,  but  not  broken 
obliquely,  and  there  was  much  comminution  between  it  and  the  con- 
dyles ;  the  compact  layer  on  the  posterior  face  of  the  bone  was  pressed 
in  toward  the  centre  as  if  the  lower  fragment  had 
been  bent  violently  backward  upon  the  other. 

The  recognition  of  the  main  line  of  fracture  is 
easy  by  attention  to  the  usual  signs ;  that  of  the 
line  between  the  condyles  is  made  by  noting  the 
independent  mobility  of  the  two  condyles  on  each 
other  when  they  are  grasped  and  moved  backward 
and  forward,  and  pain  when  they  are  pressed  to- 
gether laterally. 

Shortening  of  the  limb  is  common,  but  the  sign 
is  seldom  needed  for  the  diagnosis ;  in  an  impacted 
fracture  it  might  be  useful  in  distinguishing  the 
lesion  from  fracture  of  one  condyle  alone. 

Enlargement  of  the  knee  by  separation  of  the 
condyles  is  rare,  or  at  least  is  difficult  of  recogni- 
tion ;  on  the  other  hand,  enlargement  by  effusion 
or  hemorrhage  into  the  joint  is  constant. 
Prognosis.     The  prognosis  is  serious  as  regards  both  the  life  of  the 
patient  and  the  integrity  of  the  joint.     Of  26  cases  collected  by  Hen- 


Intercondyhiid  Iracture 
of  lemur. 


Fig.  294. 


Plaster  splints.    A  is  a  wire  attached  for  the  purpose  of  suspension. 

nequin  7  died,  3  were  amputated,  and  16   recovered.      Tlie  gravity  of 
the  injury  depends  mainlj  upon  the  implication  of  the  joint  and  the 


FRACTURES  OF   THE  FEMUR.  413 

traumatic  arthritis  excited  thereby,  which  may  easily  end  in  suppura- 
tion and  which  in  any  case  is  very  hkely  to  result  in  more  or  less  stiff- 
ness. 

Treatment.  As  the  tendency  to  overriding  and  angular  displacement 
(except  when  the  main  fracture  is  oblique)  is  not  so  marked  as  in  the 
higher  fractures,  continuous  traction  need  not  be  so  vigorous  or  so  pro- 
longed. I  prefer  the  position  of  slight  flexion  of  the  knee  and  there- 
fore habitually  use  the  Hodgeu  splint.  Or  the  limb  may  be  simply 
kept  on  a  double  inclined  plane,  or  snspended  by  an  anterior  splint  or 
a  wire  gutter,  or  encased  in  plaster  or  in  plaster  splints. 

Because  of  the  length  of  the  limb  above  the  fracture  and  the  more 
secure  hold  thereby  given  to  a  splint,  the  limb  may  be  put  in  plaster  or 
in  splints  and  the  patient  allowed  to  leave  the  bed  earlier  than  in  other 
fractures  of  the  shaft. 

Injury  to  the  popliteal  vessels  may  necessitate  amputation.  The 
indication  is  given  by  the  appearance  of  gangrene  of  the  leg  or  by 
direct  recognition  of  the  injury  to  the  vessels.  It  may  be  proper  at 
the  beginning  in  a  compound  case  to  try  to  save  the  limb  by  ligature 
of  the  torn  artery  or  by  suturing  the  deep  soft  parts  over  the  vein  if 
that  is  only  partly  torn  across ;  if  both  are  torn  immediate  amputation 
is  justifiable. 

B.  Separation  of  the  Epiphysis. 

Traumatic  separation  of  the  lower  epiphysis  of  the  fenmr  is  relatively 
frequent,  and  reports  of  cases,  generally  treated  by  operation,  frequently 
appear.  The  first  paper  dealing  specifically  with  separation  of  this 
epiphysis  was  a  very  complete  one  by  Delens.^  Later  ones  are  by 
J.  H."Packard,2  J.  Hutchinson,  Jr.,^  R.  H.  Harte,"  A.  H.  Meisenbach/ 
McBurney,®  and  M.  v.  Brunu.'^ 

Although  the  epiphysis  may  not  unite  with  the  shaft  before  the 
twenty-fifth  year,  in  none  of  the  reported  cases  has  the  patient  been 
more  than  twenty  years  of  age. 

Cause.  The  cause  in  almost  all  cases  has  been  great  violence,  extend- 
ing or  abducting  the  knee,  and  in  a  singularly  large  proportion  of  cases 
it  has  been  the  engagement  of  the  leg  between  the  spokes  of  a  revolving 
wheel.  In  one  or  two  cases  the  injury  has  been  inflicted  upon  the 
infant  during  delivery  by  the  feet  and  has  then  been  attributed,  but 
probably  incorrectly,  to  direct  traction.  In  a  few  cases  the  injury  has 
been  caused  in  attempts  to  straighten  a  stiff  knee  or  in  osteoclasis  for 
deformity. 

Pathology.  The  separation,  as  is  the  rule  also  at  other  points,  takes 
place  between  the  conjugal  cartilage  and  the  diaphysis,  is  usually  com- 
plete and  clean,  but  sometimes  leaves  attached  to  the  epi})hysis  one  or 
more  scales  broken  from  the  diaphysis  or  diverges  to  pass  through  a 

'  Delens:  Archives  Gciu'ralcs  clc  Medeciiio,  1S,S4,  vol.  xiii,  p.  272. 

2  Packard:  Annals  of  fJyiiccolofzy  and  Pu'diatrw   Novonihcr,   1S90. 

3  Hutchinson:  British  Alodical  Journal,  Deconihcr,   1JS94,  p.  G71. 
■*  Harte:  Transactions    American    Surgical    Association,    1895. 

6  Meisenbach:   Medical  Record,  October  5,  1895. 

6  McBurney:  Annals  of  Surgery,  March,  1895. 

'  V.  Brunn:  Beitrage  zur  kiln.  Chir.,  vol.  52.  p.  594. 


414 


FRACTURES. 


portion  of  the  diaphysis.    The  periosteum  is  always  freely  stripped  from 
the  shaft,  often  for  several  inches,  remaining  attached  to  the  epiphysis 


Fig.  295. 


Fig.  296. 


Separation  of  lower  epiphysis  of  femur;  displacement  forward  with  rotation  about  the  transverse  axis. 

as  an  irregular  sleeve.  In  a  few  cases  the  epiphysis  has  in  addition 
been  split  longitudinally  between  the  condyles.  The  common  displace- 
ment is  of  the  epiphysis  forward  and  to 
one  side,  usually  the  inner,  corresponding 
apparently  to  production  by  hyper-exten- 
sion of  the  knee;  in  other  cases  it  has 
been  to  the  inner  or  the  outer  side, 
doubtless  when  produced  by  abduction 
or  adduction.  When  displaced  forward 
it  has  also  passed  upward  and  upon  the 
anterior  surface  of  the  shaft  with  or 
without  rotation  (Fig.  295).  In  a  few 
cases  it  has  been  rotated  about  the 
vertical  axis  so  that  one  condyle  pre- 
sented in  the  popliteal  space,  in  others 
about  a  transverse  axis  so  that  the  sur- 
face of  separation  was  directed  back- 
ward. 

The  knee-joint  is  not  often  involved, 
but  sometimes  the  capsule  is  torn  and 
the  joint  filled  with  blood  and  exudate. 
In  a  large  proportion  of  cases  the  injury 
has  been  compound,  the  lower  end  of  the  shaft  projecting  through  the 
skin  on  the  side  or  in  the  popliteal  space.    The  popliteal  vessels  have 


Separation  of  the  lower  epiphysis  of 
the  femur.  Incomplete  displacement 
forward.  (St.  Bartholomew's  Hos- 
pital, Poland.) 


FRACTURES  OF   THE  FEMUR. 


415 


been  torn  or,  more  frequently,  so  pressed  upon  that  circulation  was 
interrupted  or  seriously  diminished.  In  one  case  a  popliteal  aneurism 
appeared  several  years  later  and  was  attributed  to  the  accident. 

In  some,  even  of  the  cases  which  were  not  compound,  suppuration 
has  ensued ;  in  others  the  pressure  of  the  end  of  the  fragment  has  caused 
the  skin  to  slough,  and  in  others  gangrene  of  the  leg  followed. 

In  a  few  cases  of  recovery  without  displacement  arrest  or  diminution 
of  growth  has  been  observed.  Puzey  ^  noted  in  a  lad  sixteen  years  old 
at  the  time  of  the  accident  shortening  of  one  inch  three  years  later. 
In  other  cases  examined  with  reference  to  this  point  growth  has  not 
been  interfered  with. 

Symptoms.     Examination  under  anaesthesia  should  make  it  possible, 

Fig  297. 


'Separation  of  lower  epiphysis  of  the  femur. 

unless  the  swelling  is  too  great,  to  establish  the  identity  of  the  two 
fragments  and  their  relations  to  each  other,  to  recognize  that  one  is  the 
lower  end  of  the  shaft  and  the  other  the  epiphysis  in  normal  relations 
with  the  tibia.  This  excludes  dislocation;  and  then  the  distinction 
between  low  fracture  through  the  shaft  and  separation  of  the  epiphysis 
is  made  by  the  character  of  the  crepitus — bony  in  one  case,  possibly  car- 
tilaginous in  the  other — the  age  of  the  patient,  and  the  relations  of 
the  line  of  fracture  to  the  adductor  tubercle  which  lies  immediately 
above  the  conjugal  cartilage. 

1  Puzey:  Liverpool  Medico-Chirurgical  Journal,  January,   1885,  p.  41. 


416  FRACTURES. 

VThen  tlie  injury  is  compound  the  denudation  of  the  shaft  and  the 
regular,  slightly  curved  surface  of  its  end  demonstrate  its  character. 

Ruptm-e  of,  or  pressure  upon,  the  artery  is  sho^^^n  by  the  absence  of 
pulsation  in  the  vessels  below;  rupture  of  the  vein  might  be  suspected 
if  the  bleeding  was  profuse  and  venous,  but  could  be  demonstrated  only 
by  direct  inspection. 

Treatment.  The  recorded  cases  show  a  very  large  proportion  of  am- 
putations, primary  or  secondary,  and  of  deaths  from  shock,  infection, 
and  operation,  but  it  seems  reasonable  to  believe,  especially  in  view  of 
some  of  the  later  cases,  that  the  future  will  show  much  better  results. 
Patients  have  suffered  in  the  past  both  from  infection,  which  can  now 
be  more  generally  avoided,  and  from  a  consequent  reluctance  to  take 
the  chances  of  conservative  treatment  in  compound  injuries  or  to  make 
an  incision  in  the  simple  ones  in  order  to  effect  reduction.  Some  of 
the  amputations  have  clearly  been  justified,  and  will  still  be  justified 
in  similar  cases,  by  the  extent  of  the  injury  to  the  soft  parts,  but  I 
feel  sure  that  a  much  larger  proportion  of  the  compound  injuries  will 
be  successfully  treated  with  preservation  of  the  limb,  and  of  the  simple 
ones  with  restoration  of  form  and  function. 

If,  in  a  simple  case  uncomplicated  by  injury  to  the  vessels,  complete 
reduction  of  the  displacement  cannot  be  made  by  traction  and  manip- 
ulation, it  would  be  not  only  proper,  but,  I  think,  imperative,  to  expose 
the  fracture  by  a  longitudinal  incision,  preferably  on  the  outer  side  in 
front  of  the  tendon  of  the  biceps,  in  order  to  overcome  the  obstacle, 
which  would  doubtless  be  the  interposed  periosteum  and  perhaps  some 
muscular  bundles.  Schuchardt^  reports  a  successful  case,  and  I  have 
had  one. 

In  a  compound  case  free  enlargement  of  the  wound  in  the  skin  and 
fascia  would  probably  make  reduction  possible  without  the  aid  of  resec- 
tion of  the  end  of  the  shaft.  If  the  injury  to  the  vessels  is  such  that 
the  vitality  of  the  limb  cannot  be  preserved,  amputation  must  be  done, 
and  it  should  be  as  low  as  the  condition  of  the  soft  parts  will  permit, 
that  is,  through  or  a  short  distance  above  the  fracture.  It  seems  even 
possible  that  in  some  cases  the  amputation  might  be  done  a  short  dis- 
tance below  the  knee  so  as  to  preserve  that  joint  to  the  patient. 

C.  Fracture  of  Either  Condyle. 

Fracture  of  a  single  condyle  may  be  caused  by  direct  violence,  as  in 
a  fall  upon  the  bent  knee,  or  by  a\Tilsion,  the  force  being  exerted 
through  one  of  the  lateral  ligaments  to  tear  oft'  one  condyle  by 
bending  the  leg  toward  the  opposite  side,  or  by  the  direct  pressure  of 
the  head  of  the  tibia  against  the  condyle  on  the  side  toward  which  the 
leg  is  bent.  ("See  also  Fractures  of  the  Upper  End  of  the  Tibia.)  In  a 
case  reported  by  A.  H.  Crosby-  the  fracture  was  caused  by  a  twist  of 
the  leg  while  the  patient,  a  youth  of  twenty-one  years,  was  resting  his 
entire  weight  upon  it. 

1  Schuohardt :  Beil.  ziim  Centralblatt  fiir  Chirurgie.   1910,   p.   146. 

2  Crosby:  Xew  HampsMre  .Journal  of  Medicine,   1S57. 


FRACTURES  OF   THE  FEMUR. 


417 


Fig.  298. 


The  specimens  of  fracture  of  a  single  condyle  are  not  numerous,  but 
they  show  that  the  line  may  run  for  a  considerable  distance  upward 
from  the  intercondyloid  notch  so  that  the  fragment  terminates  abo\'e  in 
a  long  point,  or  it  may  turn  abruptly  above  the  edge  of  the  articular 
cartilage  toward  the  side  of  the  bone.  A  unique  case  of  fracture  of  the 
posterior  portion  of  the  external  condyle  was  reported  by  Braun.^ 

The  fragment  may  be  displaced  upward,  or  to  one  side,  or  it  may  be 
swung  around  so  as  to  lie  partly  behind  or  partly  in  front  of  the  femur, 
usually  the  former.  As  it  remains  attached  to 
the  tibia  the  first  and  third  displacements  are 
indicated  by  the  posture  of  the  leg,  the  second, 
which  is  very  rare,  by  the  greater  breadth  of  the 
knee. 

As  the  displacement  is  usually  slight,  and  the 
connections  untorn,  the  injury  may  easily  be  over- 
looked, or,  if  suspected,  not  recognized  with  cer- 
tainty. In  a  case  under  the  care  of  Gosselin 
(quoted  by  Trelat)  the  patient  was  treated  for 
more  than  a  month  for  a  supposed  arthritis  of  the 
knee ;  he  grew  weaker  daily  and  died  of  exhaus- 
tion. At  the  autopsy  the  joint  was  found  full  of 
pus  and  one  of  the  condyles  broken.  The  frag- 
ments were  in  exact  apposition,  but  there  was  no 
sign  of  repair.  The  diagnosis  must  be  made  upon 
the  localized  pain,  ecchymosis,  loss  of  function, 
and  abnormal  mobility  and  crepitus,  recognized 
by  direct  manipulation  of  the  condyle  or  by 
moving  the  leg  laterally  or  in  the  direction  of 
flexion  and  extension. 

The  reported  cases  show  a  remarkable  variety  in  their  coui'se  and 
terminations.  Some  patients  have  recovered  without  greater  reaction 
than  would  be  expected  after  a  simple  non-articular  fracture ;  in  others 
the  joint  has  suppurated,  and  the  case  has  terminated  fatally ;  in  Dr. 
Crosby's  case  the  fragment  was  removed  six  months  afterward,  by 
operation,  and  the  patient  made  a  complete  recovery ;  and  in  a  case 
first  seen  by  Hamilton  three  months  after  the  injury,  the  fragment 
remained  ununited  and  could  be  moved  upward  half  an  inch  with  dis- 
tinct crepitus  and  pain  by  flexing  the  knee.  During  the  next  two  years 
the  usefulness  of  the  limb  increased  steadily. 

Treatment.  The  treatment  consists  in  reduction  of  such  displacement 
as  may  exist  by  acting  upon  the  fragment  through  the  lateral  ligament 
and  the  leg,  and  prevention  of  its  recurrence  by  keeping  the  leg  fixed 
in  the  position  to  which  it  has  been  brought  in  making  the  reduction. 
As  the  lateral  ligaments  are  tense  when  the  knee  is  extended,  and  relaxed 
when  it  is  flexed,  the  extended  position  is  the  one  which  gives  most 
security.  The  objection  urged  by  Malgaigne,  that  it  favors  anchylosis, 
is,  I  think,  unfounded;  we  know  that  the  common  cause  of  anchylosis 
lies  in  the  severity  or  the  prolongation  of  an  arthritis,  not  in  the  posi- 

•  Braun:  Arch,  fiir  klin.  Chir.,  vol.  xlii.  p.  108. 


Fracture  of  the  internal 
condyle  of  the  femur. 


418 


FEACTURES. 


Fig.  299. 


tion  in  Avliich  the  joint  is  kept.  In  the  flexed  position  of  the  knee  a 
slight  displacement  upward  of  the  fragment  could  occur  easily,  and  it 
would  certainly  pass  unrecognized  so  long  as  the  position  was  kept, 
and  would  show  itself  in  abduction  or  adduction  of  the  leg  as  soon  as 
it  was  extended,  I  prefer,  therefore,  to  treat  a  case  in  the  extended 
position  upon  a  posterior  splint  or  in  a  plaster  bandage.  A.fter  three 
or  four  weeks  the  knee  may  be  partly  flexed  if  the  fragment  has  lost 
its  mobility. 

Massage  is  useful  to  shorten  the  period  of  convalescence  and  hasten 
the  restoration  of  function.  Incision  of  the  joint  for  the  removal  of 
a  large  amount  of  blood  from  it  could  probably  be  safely  done  and 
would  diminish  the  chance  of  limitation  of  motion. 

D.   Fracture  of  the  Internal  Epicondyle. 

This  injurv  was  first  described  by  Stieda  ^  on  the  basis  of  four  cases 
observed  bv  himself.    VogeP  reported  five  cases,  Ishimoto  and  Kaneko^ 

six,  and  Draudt^  two.  In  addition  to 
the  clinical  history  there  are  the  .r-ray 
findings  in  most  of  the  cases  and  a  frag- 
ment removed  in  three. 

The  injury  appears  to  be  the  breaking 
off  of  a  scale  of  bone  about  half  an  inch 
in  diameter  from  the  side  of  the  condyle 
at  points  corresponding  to  the  insertion 
of  the  inner  head  of  the  gastrocnemius 
and  the  adductor  and  the  internal  lateral 
ligament.  In  some  of  the  cases  a  blow 
had  been  received  upon  the  side  of  the 
knee.  It  is  uncertain  whether  the  frac- 
ture is  caused  by  a  direct  blow  or  by 
avulsion  through  the  attached  muscles, 
but  the  former  is  thought  probable.  This 
interpretation  of  the  findings  has  been 
questioned  by  Pfister^  and  Preiser.^  who 
think  the  supposed  fragment  is  a  post- 
traumatic ossification  or  (Preiser)  due  to 
the  avulsion  of  a  strip  of  periosteum  by 
the  adductor  tendon.  In  all  the  cases  the  immediate  reaction  was  quite 
sharp,  the  patient  being  disabled  for  at  least  a  fortnight. 

In  two  of  the  cases  the  fragment  appeared  to  have  reunited,  in  one 
or  two  others  to  have  been  absorbed.  Under  the  ir-rays  the  fragment 
appeared  as  a  somewhat  crescentic  shadow  separated  1  or  2  nmi. 
from  the  condyle.  There  was  local  pain  on  pressure,  an  effusion  in  the 
joint,  no  pain  on  abduction  or  adduction  of  the  leg.  In  Draudt's  two 
cases  the  frao-ment  was  laro-er  and  situated  Lnver  on  the  side  of  the 


Fracture  of  the  interniil  epicondyle 
of  the  femur.    iStfeda.) 


1  Stieda:  Arch,  fur  klin.  Chir..  190S,  vol.  Ixxxv.  p.  S14. 

^  Vogel ;  Ibid.,  vol.  Ixxsix.  p.  1076. 

5  Ishimoto  and  Kaueko  :  Amer.  .Tour.  Orthop.  Surg..  1911.  ix.  241. 

*  Draudt :  Arch,  fiir  klin.  Chir..  1911,  vol.  xcvi.  p.  530. 
''  Pfister:  Arcli.  fiir  klin.,  Chir.,  vol.  Ixxxix.  p.  912. 

*  Preiser  :  Ibi<l.j  vol,  Ixxx.  Part  I. 


PLATE  XXIII 


Fig.  1. — Fracture  of  the   Internal  Epieondyle  of  the   Femur. 


Fig.  2. — Fracture  of  tlie  External   Tuberosity  of  tlie  Femur 


FRACTURES  OF  THE  FEMUR.  419 

condyle  ;  both  followed  a  blow  on  the  knee,  and  the  skiagram  was  taken 
promptly.  Some  of  the  reported  cases  are  unquestionably  fractures, 
but  those  in  which  the  skiagrams  were  not  taken  until  after  the  lapse 
of  a  few  weeks  are  doubtful. 

E.  Fracture  of  the  External  Tuberosity. 

I  have  seen  one  case  of  fracture  of  the  external  tuberosity,  apparently 
l)y  avulsion  through  the  lateral  ligament.  The  patient,  a  lady  al)out 
sixty  years  old,  who  within  the  three  preceding  years  had  broken  both 
patellar,  was  thrown  down  while  walking  by  a  man  who  stepped  l)ack 
against  her  side.  The  fragment,  as  shown  in  Plate  XXIII.,  Fig.  1., 
seems  to  comprise  most  of  the  tuberosity. 

30 


CHAPTEK  XXIV. 

FEACTUKES  OF  THE  PATELLA. 

According  to  published  records  fractures  of  the  patella  represent 
from  one  to  two  per  cent,  of  all  fractures.  They  are  much  more  fre- 
quent in  men  than  in  women,  and  in  middle  life  than  in  childhood  or 
old  age.  The  youngest  of  Malgaigne's  patients  was  eleven  years  old, 
and  he  knew  of  no  other  younger  than  seventeen  years.  The  youngest 
patient  in  the  127  cases  collected  by  Hamilton  was  live  years  old,  and 
the  fracture  was  very  different  from  the  usual  one  since  only  a  small 
piece  was  broken  from  the  margin  of  the  bone  by  a  direct  blow;  his 
next  youngest  case  was  sixteen  years  old,  and  in  this  also  the  fracture 
was  by  direct  violence.     Dittmer^  reports  one  in  a  boy  nine  years  old. 

Causes. 

The  cause  may  be  direct  or  indirect,  a  blow  or  fall  upon  the  patella 
or  the  sudden  vigorous  contraction  of  the  quadriceps  femoris,  or 
the  sudden  flexing  of  the  knee  against  the  opposition  of  the  quadri- 
ceps. The  statistics  that  have  been  collected  to  show  the  relative  fre- 
quency of  these  varieties  vary  widely  and  are,  I  think,  untrustworthy 
because  of  the  difficulty,  or  rather  the  impossibility,  in  many  cases  of 
recognizing  the  mode  in  which  the  fracture  has  been  produced.  The 
patient  slips  or  stumbles,  makes  an  effort  to  save  himself,  falls,  and 
the  patella  is  found  to  be  broken.  He  is  unable  to  say  whether  he 
struck  upon  the  patella  or  upon  the  tuberosity  of  the  tibia,  whether 
directly  in  front  or  upon  the  side,  or,  and  this  I  have  often  met  with, 
he  asserts  that  he  fell  upon  the  patella  because  he  knows  it  is  broken, 
and  cannot  understand  that  the  lesion  could  have  been  produced  in  any 
other  way.  If  the  examination  is  pushed,  and  the  question  asked,  "  How 
do  you  know  it?"  the  answer  is  often,  "  Why,  it  must  have  been  so." 

My  own  conviction  is  that  the  efficient  agent  in  the  great  majority 
of  cases  is  the  contraction  of  the  quadriceps,  either  directly  or  by  the 
forced  flexion  of  the  knee  against  its  opposition,  and  the  grounds  for 
this  belief  are  the  numerous  cases  in  which  this  mode  of  production 
can  be  clearly  demonstrated,  the  practical  impossibility  of  producing 
any  but  a  comminuted  fracture  experimentally  by  direct  violence,  and 
the  position  of  the  patella,  which  is  such  that  the  blow  is  rarely 
received  upon  it  in  a  fall. 

The  question  whether  muscular  contraction  breaks  it  by  direct  trac- 
tion or  by  bending  it  over  the  convexity  of  the  condyles  is  of  purely 
academical  interest,  and  in  most  cases  it  cannot  be  answered  })ositively 
because  the  position  of  the  bone  at  the  moment  of  fracture  with  refer- 
ence to  the  condyles  cannot  be  known.  In  a  few  cases  the  fracture  has 
been  caused,  beyond  question,  by  simple  traction  without  bending  or 
cross-strain,  as  in  a  case  reported  by  Garreau  ^  in  which  a  second  frac- 
'  Dittmer :  Langenbeck's  Archives,  vol.  lii.  ^  Garreau :  Eevue  Medico-Cliirurg.,1853,  p.  375, 
(420) 


FRACTURES  OF   THE  PATELLA.  421 

ture  by  muscular  action  occurred  in  the  upper  fragment  twelve  years 
after  the  first  fracture  had  healed  with  a  separation  of  four  centimetres 
(If  inches).  In  others  it  is  equally  certain  that  the  traction  of  the  liga- 
mentum  patella?  was  inclined  somewhat  backward  from  the  long  axis  of 
the  patella,  the  fracture  taking  place  when  the  limb  was  partly  flexed. 

Le  Dentu  {Bull,  de  VAcad.  de  Med.,  November,  1912,  p.  431)  says 
it  occiu-s  occasionally  in  the  tabetic  without  other  apparent  cause  than 
quiet  walking. 

The  common  clinical  form  is  a  vigorous  contraction  of  the  quadri- 
ceps, either  simply  in  voluntary  use  of  the  limb  or  aided  by  forced 
flexion  of  the  knee  by  forces  which  overcome  the  opposition  of  the 
muscles.  Thus,  a  man  jumps  and  breaks  the  patella,  or  he  fails  in  an 
eftort  to  avoid  a  fall  and  the  leg  is  bent  under  him,  or,  as  in  a  case  of 
my  own,  he  seeks  to  push  a  heavy  box  with  his  foot  resting  against  its 
side  and  the  knee  partly  flexed,  the  foot  slips  down,  the  flexion  of  the 
knee  is  sharply  increased  thereby,  and  the  bone  is  broken.  This  forcible 
flexion  is  a  frequent  cause  of  early  re  fracture  while  motion  is  still 
limited  and  the  descent  of  the  upper  fragment  prevented  by  adhesions 
or  peri-articular  thickening. 

Pathology. 

In  the  great  majority  of  cases  by  indirect  violence  the  fracture  is 
transverse  or  slightly  oblique,  and  usually  at  or  just  below  the  middle 

Fig.  300.  Fig.  301. 


^W      ^^^ f^  Comminuted  fracture  of  the 

^^^^  patella.    Bony  union.   Exuber- 

Unusual  form  of  fracture  of  patella,  a,  anterior  surface ;          ant  callus   at    several  points. 

B,  mesial  section.  (Gurlt.) 

of  the  bone;  sometimes  it  lies  very  near  one  end  of  the  bone,  es])e- 
cially  the  lower,  and  once  or  twice  I  have  seen  it  crossing  and  separating; 
only  the  upper  inner  corner.  Hoffa  ^  saw  a  fracture  of  a  small  piece  of 
the  outer  border  by  muscular  action.  I  have  occasionally  seen  the 
lower  fragment  split  longitudinally,  and  I  have  seen  one  case  (Fig.  800) 
in  which  on  inspection  through  an  incision  the  surface  of  fracture  was 
found  to  be  very  oblique  downward  and  backward  and  was  also  curved 
downward  on  the  anterior  aspect.    Parke-  reports  a  somewhat  similar 

•  IIf)ff;i:   Deutsfhc  Med.  Woohon.schrift,  Ver  Boil,  1903,  p.  111. 
2  Parke:  New  York  Medical  Journal,  March,  1S9.3,  p.  303. 


422  FRACTURES. 

one  seen  two  months  after  the  accident;  the  mjury  was  apparently 
caused  by  du-ect  lateral  pressure,  and  the  upper  and  posterior  fragment, 
comprising  nearly  half  the  bone,  lay  wholly  above  the  other. 

A  unique  case  of  fracture  in  the  frontal  plane — anterior  and  posterior 
fragments — with  outward  dislocation  of  the  posterior  piece,  is  reported 
by  Ivroner  in  Centralblatt  fiir  Chir.,  1904,  p.  14G9.  He  thought  the 
dislocation  preceded  the  fracture. 

Longitudinal,  comminuted,  and  some  oblique  fractiues  are  due  to 
direct  violence,  and  rarely  show  much  displacement.  A  unique  case  of 
longitudinal  fracture  by  muscular  action  was  reported  to  me  by  Dr.  A. 
Freeman:  A  young  man  while  dancing  slipped  and  fell;  he  rose  and 
continued  to  dance  but  was  soon  stopped  by  pain.  The  .r-ray  showed 
a  longitudinal  fracture  at  the  junction  of  the  outer  third  and  inner 
two-thirds. 

The  displacement  after  transverse  fracture  is  ordinarily  well  marked, 
its  degree  being  modified  by  the  extent  to  which  the  periosteum  and 
lateral  expansions  are  torn.  Occasionally  there  is  none.  The  separa- 
tion, which  may  be  an  inch  or  more,  is  due  in  part  to  the  retraction 
of  the  quadriceps  and  the  tension  of  the  fascia  lata  and  in  part  to  dis- 
tention of  the  joint  by  blood  and  exudate.  "\Miile  the  injury  is  fresh 
the  quadriceps,  even  when  actively  contracted,  can  rarely  separate  the 
fragments  for  more  than  a  short  distance  when  the  knee  is  fully  ex- 
tended and  the  hip  somewhat  flexed.  Later,  if  the  fragments  remain 
ununited,  the  gradual  shortening  of  the  muscles  increases  the  interval. 

A  third  cause,  which  acts  less  promptly,  is  the  gradual  retraction 
of  the  ligamentum  patellse;  in  one  of  ]\Ialgaigne's^  old  cases  it  was 
shortened  one-half,  measiuing  only  three  centimetres,  and  in  one 
reported  by  Brunner^  it  was  shortened  more  than  two-thirds. 

Occasionally  the  lower  fragment  is  so  rotated  that  its  fractured 
surface  is  directed  forward. 

The  other  displacements  are  more  readily  recognizable  later.  They 
are  lateral  and  angular,  the  angle  pointing  forward,  backward,  or  to 
one  side.  Lateral  angular  displacement  appears  to  be  commonly 
the  result  of  uneven  stretching  of  the  fibrous  union  after  the  patient 
begins  to  use  the  limb;  anterior  angular  displacement  is  not  only 
produced  by  the  pressure  of  pads  or  bandages  above  and  below  the 
fragments  when  the  latter  are  in  contact,  or  nearly  so,  but  it  is  also  the 
inevitable  effect  of  separation  by  distention  of  the  joint,  and  may 
apparently  be  caused  by  cicatricial  retraction  of  the  lateral  soft  parts. 
I  have  seen  in  a  skiagram  the  upper  fragment  turned  so  that  its  frac- 
tured surface  was  directed  backward  (Fig.  310j. 

The  associated  injuries  to  the  soft  parts  have  become  well  known 
through  the  opportunities  for  direct  inspection  furnished  by  frequent 
resort  of  late  to  open  arthrotomy  in  treatment.  They  involve  the 
fibro-periosteal  envelope  of  the  front  of  the  bone,  the  lateral  expansions 
and  capsule  on  the  sides,  and  the  fascial  ex])an-i(iii>  downward. 

1  Malgaigne:  Atlas,  Plate  XIV,  Fi?.  4,  and  p.  17. 

2  Brunner:  Deutsche  med.  Wochenschrift,  May  17,  1888. 


FRACTURES  OF   THE  PATELLA. 


423 


The  fibro-periosteal  layer  on  the  front  of  the  bone  is  usually  torn 
at  a  level  different  in  part  from  that  of  the  fracture  and  rather  irregu- 
larly, so  that  it  projects  from  the  edge  of  one  or  the  other  fragment, 
usually  the  upper,  as  a  ragged  fringe,  sometimes  fully  half  an  inch 
wide,  which  drops  over  the  fractured  surface  and  is  thus  interposed 
between  the  fragments  when  they  are  brought  together.  Macewen  was 
the  first  to  call  special  attention  to  this  fringe  and  to  suggest  that  it 
might  be  a  bar  to  close,  firm  union.  It  is  sometimes  notably  sup])le- 
mented  by  one  or  more  long  strips  of  fascia  (I  have  seen  them  more 
than  four  inches  long)  attached  to  the  upper  fragment  and  drawn  up 
from  the  region  immediately  below,  lying  curled  up  in  the  joint  between 
the  fragments.  The  lateral  expansions  and  the  capsule  are  freely  torn 
on  each  side  transversely,  except  in  the  rare  cases  without  separation. 

The  fracture  may  be  made  compound  by  direct  violence  or  by  tear- 
ing of  the  skin  in  the  separation  of  the  fragments  when  it  has  become 
adherent  to  the  patella  by  an  inflammatory  or  cicatricial  process.  The 
common  instances  of  the  latter  are  in  refracture,  especially  after  opera- 
tive treatment  of  the  first  fracture;  much  more  rarely  in  a  primary 
fracture  after  a  wound  of  the  skin  which  has  not  entirely  healed. 


Fig.  302. 


Symptoms. 

In  fractures  by  muscular  action,  with  or  without  a  fall,  a  sharp 
crack  may  be  heard  and  the  patient  is  usually  unable  to  use  his  limb. 
In  a  few  cases  he  has  walked,  and,  indeed,  in  most  it  is  possible  to 
walk  backward,  keeping  the  knee  extended  by  the  pressure  of  the  heel 
on  the  ground,  or  even  to  walk  forward  if  the  uninjured  limb  is 
advanced  and  the  other  swung  up  to  it  but  not  beyond  it. 

The  knee  becomes  promptly  swollen  by  an  effusion  of  blood  or 
synovia  into  it  and  by  tumefaction  of  the  soft 
parts,  and  the  two  fragments,  separated  usually 
by  a  well-marked  interval,  can  be  made  out  and 
their  independent  mobility  recognized.  This 
mobility  may  be  very  slight  if  the  fragments  are 
close  together.  Crepitus  can  often  be  felt  when 
the  fragments  are  pressed  together. 

The  subjective  symptoms  are  moderate  pain 
when  the  limb  is  at  rest,  increased  by  movement 
and  by  pressing  the  fragments  together  and  by 
pressure  along  the  edge  of  a  fragment,  and  in- 
ability actively  to  extend  the  leg  or  to  raise  the 
heel  from  the  bed.  It  must  be  remembered  that  in 
rare,  entirely  exceptional,  cases  the  fibrous  covering 
of  the  bone  may  remain  untorn  and  constitutes 
a  sufficient  connection  between  the  fragments  to 
make  a  limited  use  of  the  limb  possible. 

In   longitudinal   or  comminuted   fractures   the 
signs  recognized  by  palpation  will  vary  in  accord- 
ance with  the  differences  in  the  lines  of  the  fracture,  and  in  the  former 
active  extension  will  be  prevented  only  by  the  pain  attending  the  cfl'ort. 


-  A 


Bony  union  after  frac- 
ture of  the  patella.  (Speci- 
men 201  of  the  Mus6e 
Dupuytren.) 


424 


FRACTURES. 


Course  and  Termination. 

The  region  swells  promptly,  partly  by  reaction  of  the  overlying  soft 
parts,  partly  by  the  distention  of  the  joint  by  blood  and  synovia;  the 
swelling  can  be  largely  prevented  or  rapidly  reduced  by  methodical 
pressure,  preferably  by  an  elastic  bandage. 

If  the  fragments  are  kept  fairly  well  together  and  if  neither  is  tilted 
a  fibrous  bond  forms  between  them  which  may  ossify  wholly  or  in 


Fig.  304. 


Fig.  305. 


r 


Fibrous  union  with  great 
separation,  after  fracture 
of  the  patella.  The  band 
adheres  to  the  broken  sur- 
face of  the  lower  fragment. 
(Holmes's  System.) 


Long  fibrous 
union. 


Hypertrophy  of  patella  after  fracture 
and  wiring. 


part  if  the  contact  is  very  exact  (Figs.  302,  310,  311,  312  and  313), 
but  which  in  cases  not  treated  by  operation  almost  always  remains 
fibrous  and  usually  lengthens  somewhat  under  use  during  the  first 
few  months.  Even  in  some  operative  cases  which  have  again  come 
to  direct  inspection  after  many  months,  the  union  which  was  so 
close  that  no  independent  mobility  could  be  recognized  has  been  found 
to  be  fibrous.  Some  of  the  skiagrams  I  have  taken  have  shown  bony 
union  only  in  the  posterior  half  or  three-fourths.  They  also  show  an 
angular  displacement  producing  a  slight  concavity  of  the  articular 
surface  which,  according  to  Chaput,^  favors  full  restoration  of  func- 
tion.    If  the  fragments  are  not  kept  together,  or  if  one  is  turned  so 


1  Chaput:  Th&se  de  Paris,  1885,  and  Bull,  de  la  Soc.  Anat.,  April,  1888,  p.  459. 


PLATE  XXIV 


Fracture  of  Patella.     Ossification  of  upper  portion  of 
ligamentum  patellae. 


FRACTURES  OF   THE  PATELLA. 


425 


that  its  fractured  surface  is  directed  forward  or  backward,  the  union 
between  them  is  by  a  bond  formed  mainly  by  the  overlying  soft  parts 
(Fig.  303),  but  sometimes  by  a  thicker  one  apparently  of  new  formation 
(Fig.  304) ;  it  seems  probable  that  the  latter  form  is  produced  by  the 
elongation  of  a  shorter  bond  formed  under  favorable  conditions  of 
proximity  and  position. 

Hypertrophy  of  the  fragments  is  frequently  noticed  and  sometimes 
appears  mechanically  to  limit  flexion  of  the  knee;  occasionally  also 
bony  nodules,,  sometimes  quite  large,  form  within  the  connecting  band. 
Once  I  found  ossification  of  the  upper  half  of  the  liffanientum  patellae 
(Plate  XXiy.) 

On  the  first  attempts  to  use  the  limb,  whether  these  are  made  promptly 
or  only  after  a  month  or  two,  the  joint  is  found  to  be  very  stiff,  but 
usually  the  range  increases  quite  rapidly  and  full  active  flexion  and 
extension  are  ultimately  re-established.  In  a  certain,  not  large,  pro- 
portion of  cases  there  is  notable  loss  of  function  :  either  inability  fully 
to  flex,  or  almost  complete  loss  of  active  extension  although  the  joint 
is  freely  movable,  or  inability  to  make  complete  active  extension,  the 
limb  remaining  slightly  flexed. 

These  disabilities  coincide  with  and  presumably  depend  upon  the 
varying  conditions  of  the  fragments  and  uniting  bond  which  have  been 
described. 

Fig.  306. 


Extreme  separation  of  the  fragments  after  fracture  of  the  patella. 


Inability  to  flex  appears  to  be  largely  due  to  retraction  of  the  jiortion 
of  the  capsule  attached  to  the  upper  fragment  and  of  the  fascia  lata  on 
the  outer  side,  especially  of  the  upper  side  of  the  rent  in  the  lateral 
expansion,  and  sometimes  to  enlargement  of  the  patella,  itself  the 
result  of  hypertrophy  of  the  fragments  or  of  a  short  stiff  bond  between 
them  which  makes  the  bone  too  long  to  turn  over  the  curve  of  the 
condyles.  Retraction  of  the  quadriceps  seems  not  to  be  an  important 
factor  in  this  disability.  (See  also  the  section  on  Disability  After 
Fracture.) 


426  "FRACTURES. 

Loss  of  active  extension,  when  marked  and  when  combined  with 
free  flexion,  is  due  to  insufficient  union  between  the  fragments  and  the 
absence  of  complementary  fascial  connections  between  the  quadriceps 
and  the  leg,  such  as  are  found  in  some  cases.  It  is  most  marked  when 
the  fracture  is  in  the  lower  half  of  the  bone,  because  of  the  loss  of  the 
lower  fibres  of  the  vasti.  It  is  remarkable  that  this  loss  interferes  so 
slightly  with  ordinary  use  of  the  limb  in  most  cases ;  the  patients  often 
walk  easily  and  securely,  although  they  are  exposed  to  fall  whenever 
their  weight  rests  only  on  the  partly  flexed  limb.  They  seem  instinc- 
tively to  depend  upon  the  sound  limb  whenever  the  use  of  the  damaged 
one  would  be  unsafe.  There  is  difficulty  in  going  up-  and  do\\'nstairs 
and  in  rising  from  a  seat.  In  the  case  represented  in  Fig.  306  the 
patient  claimed  not  to  be  aware  of  any  noteworthy  defect  in  the  limb 
although  active  extension  was  almost  entirely  absent. 

The  common  defect  is  slight  limitation  of  active  extension,  the 
patient  being  unable  to  raise  the  heel  from  the  bed  without  first 
slightly  flexing  the  knee. 

Degeneration  of  the  quadriceps  in  direct  consequence  of  the  trauma 
has  been  alleged  as  a  cause  of  diminution  of  the  power  of  active  exten- 
sion, and  has  been  used  as  an  argument  for  early  resort  to  massage. 

Rupture  of  the  uniting  band  or  bone  {"  refracture  ")  is  not  infrequent 
in  the  first  few  months,  or  even  much  later  when  flexion  has  remained 
limited.  The  cause  is  forcible  flexion  of  the  knee  beyond  the  range 
that  has  been  acquired,  as  in  a  fall ;  it  has  occasionally  been  caused 
by  the  surgeon  in  an  attempt  to  increase  the  range  by  passive 
motion.  The  mechanism  is  the  pulling  away  of  the  lower  fragment, 
the  corresponding  descent  of  the  upper  being  prevented  by  the  pre- 
viously mentioned  conditions.  Occasionally  the  soft  parts,  including 
the  skin,  have  been  so  adherent  that  the  rupture  has  involved  them 
also,  thus  freely  opening  the  joint.  In  the  past  such  an  accident  was 
frequently  followed  by  suppuration  of  the  joint  and  the  consequent 
loss  of  limb  or  life.  This  complication  is  more  likely  to  happen  when 
the  skin  over  the  fracture  has  been  transversely  incised  in  operative 
treatment. 

Fracture  of  a  fragment  has  occurred  in  a  few  cases. 

The  course  of  a  compound  fracture  depends  on  the  occurrence  or 
avoidance  of  infection ;  if  it  is  avoided  the  course  and  termination  are 
practically  those  of  simple  fracture ;  if  it  occurs  it  creates  serious  risk 
to  life  and  limb,  leading  to  anchylosis  or  amputation. 

Treatment. 

The  obstacles  to  apposition  of  the  fragments  and  their  close  reunion 
are  the  pull  of  the  quadriceps,  the  distention  of  the  joint,  and  the  inter- 
position of  the  fibro-periosteal  fringe  or  aponeurotic  shreds.  Later 
causes  of  limitation  of  function  are  adhesions  and  retraction  of  the  soft 
parts  of  the  joint,  hypertrophy  of  the  fragments,  and  possibly  degene- 
ration of  the  quadriceps. 

The  numerous  methods  of  treatment,  which  respectively  seek  more 
or  less  specifically  to  remove  one  or  another  obstacle  or  late  conse- 


FRACTURES  OF   THE  PATELLA.  427 

quence,  may  be  grouped  as  operative  and  non-operative,  including  in  the 
former  those  in  which  the  fragments  are  mechanically-  fastened  together 
either  after  open  arthrotomy  or  by  means  introduced  subcutaneously 
or  acting  temporarily  or  permanently  through  the  punctured  skin;  in 
short,  those  which  distinctly  involve  the  chance  of  infection  of  the  joint. 

The  points  to  be  considered  in  choosing  between  these  two  main 
methods  are  that  a  long  experience  has  shown  that  non-operative 
methods  furnish  in  the  great  majority  of  cases  in  which  they  are  prop- 
erly used,  a  result  which  is  functionally  satisfactory  even  if  the  union 
of  the  fragments  is  not  close,  that  most  of  the  failures  are  apparently 
due  to  unfitness  of  the  method  chosen  or  its  faulty  use,  that  only  in  a 
small  proportion  of  cases  are  the  conditions  such  as  to  make  a  bad 
result  inevitable  without  resort  to  operative  methods,  and  that  son^<e  of 
the  later  causes  of  limitation  of  function  are  equally  active  after  either 
method  of  treatment.  That  direct  mechanical  approximation  and 
maintenance  of  the  fragments,  if  the  dangers  of  the  operation  are 
escaiDed,  practically  annuls  or  ensures  the  removal  of  the  primary 
obstacles  in  all  cases,  notably  hastens  the  restoration  of  function,  and 
probably  makes  that  restoration  more  complete  in  some  cases,  besides 
making  it  possible  in  those  in  which  otherwise  it  would  certainly  fail 
to  be  obtained,  cannot  be  denied.  On  the  other  hand,  operation  exposes 
to  infection ;  and  if  infection  occurs  the  result  is  almost  certain  to  be  a 
stiff  joint,  amputation,  or  death.  In  short,  it  takes  less  time  and  makes 
a  good  result  more  certain,  but  some  of  its  failures  are  disastrous  to  an 
extent  far  beyond  that  of  non-operative  failures. 

If  there  was  no  risk  in  an  open  operation  it  would  deserve  selection 
in  almost  every  case,  if  only  because  it  makes  possible  the  removal  of 
those  certain  causes  of  failure  which  are  sometimes  present  and  cannot 
otherwise  be  recognized  and  removed,  such  as  tilting  of  the  fragments 
and  the  interposition  of  bundles  of  fascia.  The  propriety  of  resort  to 
operation  turns,  therefore,  in  the  absence  of  special  reasons,  upon  the 
measure  of  safety  with  which  it  can  be  done,  and  while  I  believe  that 
certain  methods,  when  surrounded  by  every  precaution,  can  be  em- 
ployed with  an  assurance  of  success  that  justifies  resort  to  them,  and 
while  I  habitually  use  them,  yet  I  have  never  taught  them  as  routine 
])ractice,  but  on  the  contrary  have  strongly  advised  against  their  use 
except  by  those  who  can  bring  to  them  not  merely  experience  in  oper- 
ating but  also  the  habit  of  taking  surgical  precautions  and  the  aid  of 
trained  assistants  who  have  the  same  habit,  who  are  practising  those 
precautions  daily  ;  in  short,  the  personnel  of  an  active  surgical  hos])ital 
service.  I  do  not  mean  that  any  one  of  the  many  operative  methods 
proposed  and  used  can  be  done  with  this  assurance  of  success,  but  only 
that  the  one  with  which  I  am  familiar,  and  which  now  (February, 
1909)  I  have  used  in  fully  two  hundred  and  fifty  cases  without  acci- 
dent, can  be  so  done,  and  that  only  because  it  is  freer  than  most  ojiera- 
tions  from  those  more  or  less  unavoidable  causes  to  which  we  attribute 
our  disasters.  I  refer  especially  to  the  difficulty  of  making  tiic  hands 
clean.  The  general  practitioner,  and  even  the  occasional  surgeon,  is  not 
only  fully  justified  in  using  a  non-operative  method  but  ought  to  do  so  ; 
and  he  can  feel  assured  that  the  methods  at  his  command  justify  the 
expectation  of  a  satisfactory,  even  if  not  perfect,  result. 


428 


FRACTURES. 


1.  Non-operative  Treatment.  The  opposing  factors  specially  sought 
to  be  controlled  by  most  of  the  methods  are  the  effusion  in  the  joint 
and  the  action  of  the  quadriceps  to  create  or  maintain  separation. 

The  production  of  the  effusion  may  be  opposed  by  systematic  press- 
ure or  cold ;  its  absorption  may  be  hastened  by  pressure  or  massage,  or 
it  may  be  immediately  removed  by  puncture  or  aspiration.  I  prefer 
pressure  with  a  light  rubber  bandage;  this  will  remove  the  effusion 
rapidly  or,  if  the  case  is  seen  early,  w^ill  notably  limit  its  production. 

Immediate  removal  of  the  effusion  by  aspiration  or  puncture,  with 
or  without  washing  of  the  joint,  is  occasionally  practised,  but,  except 
in  rare  conditions  such  as  a  large  intra-articular  hsematoma^  has  no 

Fjg.  307. 


Dressing  for  fracture  of  the  pateUa.    The  final  turns  of  the  roller  in  front  of  the  knee  are  not 

shown  in  the  cut. 


marked  superiority  over  the  slower  removal  by  pressure.  If  washing 
is  done  it  should  be  with  a  hot  sterile  salt  solution,  not  with  carbolic 
acid. 

After  removal,  immediate  or  gradual,  recurrence  must  be  opposed 
by  bandaging ;  the  application  of  strips  of  adhesive  plaster  so  as 
entirely  to  cover  the  front  and  sides  of  the  joint  has  been  recom- 
mended, but  a  well-applied  roller  is  probably  equally  efficient. 

Approximation  of  the  fragments  is  effected  by  the  hands,  and  its 
maintenance  by  a  great  variety  of  devices  from  a  simple  circular 
bandage  to  complex  apparatus.  All  are  combined  with  a  posterior 
splint  for  immobilization  and  usually  with  confinement  to  the  bed  with 
the  foot  raised  for  at  least  a  month.  As  for  active  separation  of  the 
fragments  by  the  quadriceps,  full  extension  of  the  knee  with  elevation 
of  the  foot  (flexion  of  the  hip)  prevents  it. 

The  simplest  form  is  a  roller-bandage  applied  over  a  long  straight 
or,  better,  a  moulded  posterior  splint,  the  turns  immediately  above  and 
below  the  fragments  being  placed  obliquely,  as  shown  in  Fig.  307. 
Fixation  has  been  sought  in  encasement  in  plaster  of  Paris  by  pressing 
the  still  soft  dressing  snugly  down  above  and  below  the  fragments  and 
maintaining  the  pressure  until  the  dressing  has  hardened,  but  an  irre- 
movable dressing  which  prevents  inspection  exposes  to  rude  disappoint- 
ment on  its  removal,  for  as  the  limb  grows  loose  within  the  control  of 
the  fragments  is  lost  and  separation  may  occur  and  remain  unrecog- 
nized until  it  is  too  late  to  remedy  it. 


FRACTURES  OF   THE  PATELLA. 


429 


More  exact  fixation  of  the  upper  fragment  has  been  sought  by  fixed 
or  elastic  traction  on  the  skin  close  above  it,  so  applied  that  its  pressure 
will  be  downward  and  backward  and  thus  act  upon  the  fragment. 
Thus,  a  strip  of  adhesive  plaster  an  inch  or  two  wide  is  laid  "across 
close  above  the  fragment  and  its  ends  carried  downward  on  either  side 
to  the  sides  or  back  of  the  splint  at  the  calf,  as  in  Fig.  308.  For 
a  number  of  years  I  used  this  plan,  sometimes  with  a  piece  of  rubber 
tubing  interposed  on  each  side  to  make  the  traction  elastic,  and  was 
well  satisfied  with  the  results.  Sometimes  the  plaster  is  cut  ir  a  broad 
U-shape  that  it  may  fit  better. 

Fig.  308. 


Fracture  of  the  patella.    (Lat:gier.) 

Massage  has  been  strongly  recommended  to  reduce  the  swelling,  pre- 
vent adhesions,  diminish  retraction  of  the  capsule,  regenerate  the  quad- 
riceps, and  hasten  convalescence.  It  has  even  been  claimed  that  it 
could  be  trusted  to  secure  a  good  result  without  immobilization  of  the 
joint  or  confinement  to  bed,  but  even  its  most  ardent  recent  advocates 
have  not  repeated  the  claim.  I  do  not  think  it  removes  the  eff'usion  as 
rapidly  and  conveniently  as  elastic  pressure  does ;  after  the  second  or 
third  week  it  hastens  absorption  of  the  exudate  and  improves  the 
circulation  as  after  other  injuries,  but  I  doubt  if  it  does  more  than 
somewhat  shorten  the  period  of  convalescence. 

In  most  fractures  by  direct  violence  the  preservation  of  much  of  the 
periosteal  envelope  prevents  separation,  and  no  special  measures  are 
required  to  keep  the  fragments  together. 

Thomas  ^  reports  eleven  cases  to  prove  that  an  excellent  result  can  be 
easily  obtained  without  confinement  to  bed.  He  simply  immobilizes 
the  joint  by  the  splint  which  he  uses  in  disease  of  the  knee,  two  metal 
rods  lying  on  either  side,  attached  to  the  heel  of  the  shoe,  and  fitted 
with  a  perineal  band  and  three  straps,  one  each  behind  the  knee  and 
across  the  front  of  the  thigh  and  leg.     It  is  worn  for  four  or  five  months. 

To  summarize  :  an  elastic  bandage  covering  the  patella  and  six  inches 
above  and  below  may  be  applied  for  a  few  days  to  reduce  or  j)revent 
swelling,  and  if  it  keeps  the  fragments  well  together  it  may  be  con- 
tinued for  a  fortnight.  Then  the  limb  is  placed  in  a  long  posterior 
])laster  gutter  or  on  a  straight  posterior  splint  and  bandaged  from  the 
foot  to  the  upper  part  of  the  thigh,  the  turns  immediately  above  and 
below  the  fragments  being  j^hiccd  obli(iuely  as  above  shown,  and  the 
patient  is  kept  in  bed  on  his  back  with  his  foot  well  raised.  A  month 
or  six  weeks  after  the  accident  the  limb  is  encased  in  i)iastcr  and  the 


1  Thomas:  Provinr.  Medifal  Journal,  August  1,  1S!S9. 


430  FRACTURES. 

patient  allowed  to  go  about  on  crutches.  If  the  attention  can  be  given, 
the  splint  may  be  cut  open  in  front  and  removed  daily  for  massage,  and 
after  a  month  it  may  be  left  off  at  night  and  then  in  the  house  during 
the  day,  and  the  patient  encouraged  to  move  the  joint.  The  danger  to 
be  avoided  is  premature  forcible  flexion  of  the  knee,  which  is  most 
likely  to  happen  by  accident,  as  in  a  fall;  the  prolonged  use  of  the 
splint  is  mainly  as  a  protection  against  this  accident.  The  closer  the 
union  the  shorter  the  time  it  needs  to  be  worn,  but  certainly  no  great 
strain  should  be  put  upon  the  bond  until  after  the  second  month. 

A  few  methods,  which  may  be  termed    intermediate    between    the 
operative  and  non-operative,  have  been  devised  to  act  directly  upon 
the  fragments  without  the  necessity  of  opening  the  joint,  but  as  they 
require  multiple  punctures  of  the  skin  which  must  be  kept  open  for 
.  several  weeks,  and  as  these  punctures 

Fig.  309.  may  communicate   with   the   seat  of 

fracture  through  the  spaces  created 
by  the  extra vasated  blood,  the  chance 
of  infection  exists  as  in  open  opera- 
tion, while  the  work  is  done  less 
easily  and  effectively. 

Malgaigne's  hooks  (Fig.  309),  the 
earliest  of  these,  may  be  taken  as  the 
Malgaigne's  hooks.  type.     The  poiuts   of  the  hooks   are 

passed  through  the  skin  and  engaged 
respectively  in  the  upper  and  lower  ends  of  the  patella,  and  then 
brought  together  by  tlie  screw  until  the  fragments  are  coaptated.  It 
is  an  efficient  method  and  is  usually  well  borne,  but  the  presence  of 
swelling  may  make  the  application  difficult  or  impossible.  They  must 
be  worn  three  or  four  weeks.  The  danger  is  of  suppuration  about  the 
points  and  of  its  possible  extension  to  the  joint.  The  instrument  has 
been  modified  by  Levis — two  separate  pairs  instead  of  a  double  one — 
by  W.  K.  Otis,  who  made  the  individual  parts  adjustable,  and  by 
Duplay,  who  made  it  stronger  and  firmer.  It  has  furnished  many  good 
results,  and  the  accidents  following  its  use  have  been  few.  Of  course 
the  punctures  must  be  carefully  protected.  To  avoid  making  punctures 
in  the  skin  Trelat  used  two  gutta-percha  plates  moulded  to  the  surface 
above  and  below  and  engaged  the  hooks  in  them. 

I  devised  and  tried  in  a  few  cases  ^  a  modification  consisting  of  a 
two-pronged  fork  bent  on  the  flat,  which  was  engaged  in  the  upper 
fragment  with  its  shank  resting  on  the  thigh  above,  and  was  drawn 
downward  by  an  elastic  cord.  It  is  easier  of  adjustment  than  Mal- 
gaigne's hooks  and  did  the  work  equally  well,  but  suppuration  about 
the  points  was  occasionally  free.  I  long  ago  abandoned  it  for  the 
suture. 

Mayo  Robson  ^  passed  a  steel  pin  transversely  through  the  tendon  of 
the  quadriceps  close  to  the  upper  edge  of  the  patella,  and  another 
through  the  ligamentum  patellse  close  to  the  lower  edge,  and  then  drew 
the  fragments  together  and  maintained  them  by  a  ligature  about  the 
projecting  portions  of  the  pins  on  each  side.     I  should  think  it  an 

'  Stimson:  New  York  Medical  Journal,  January  3,  1885,  p.  23. 
2  Robson;  British  Medical  .Journal,  March  30,  1889. 


FRACTURES  OF   THE  PATELLA.  431 

easier  method  than  Malgaigne's.    Dieffenbach  had  long  before  driven 
pegs  into  the  fragments  and  tied  them  together. 

Anderson^  modified  Robson's  method  by  passing  the  pins  through  the 
fibro-periosteal  covering  of  the  fragments,  a  disadvantageous  change, 
I  should  think,  because  it  brings  the  punctures  nearer  the  fracture  and 
thereby  increases  the  chance  of  infection  of  the  joint  in  case  suppura- 
tion should  take  place  about  the  pins,  as  it  did  in  one  of  his  four  cases. 

Certain  other  methods  of  subcutaneous  or  temporary  fixation  which 
resemble  the  above  in  some  respects  will  be  mentioned  in  the  next 
section  because  in  all  the  joint  is  opened,  directly  or  indirectly,  through 
the  gap  made  by  the  fracture,  and  as  therefore  direct  and  early  infec- 
tion is  possible  they  should  be  compared  with  others  carrying  the  same 
risk. 

2.  Operative  Treatment.  This,  which  began,^  in  the  antiseptic 
period,  with  Lister's  exposure  of  the  fracture  and  wiring  of  the  frag- 
ments, presents  a  great  number  of  methods  and  procedures,  some  of 
which  are  a  natural  evolution  from  their  predecessors  in  the  direction 
of  simplicity,  efficiency,  or  safety,  while  others  are  merely  novelties 
obtained  at  the  price  of  some  disadvantage  or  based  upon  the  exag- 
geration of  the  importance  of  some  indication.  The  fundamental  idea 
is  the  mechanical  fixation  of  the  fragments  by  some  form  of  suture, 
and  the  associated  one  is  either  the  removal  of  the  effusion  or  of  the 
interposed  periosteal  fringe,  or  the  reduction  of  the  risk  by  the  use  of 
punctures  instead  of  a  free  incision.  Their  comparison  will  be  made 
easier  by  first  considering  certain  facts  and  general  principles. 

The  pull  of  the  quadriceps  when  the  knee  is  fully  extended  and  the 
hip  slightly  flexed  is  so  weak  that  even  when  the  muscle  is  actively 
contracted  it  will  not  separate  the  fragments  more  than  half  an  inch. 
I  have  repeatedly  observed  this  during  an  open  arthrotomy,  and  I 
have  seen  several  patients  pass  through  an  attack  of  delirium  tremens 
in  the  first  week  without  tearing  apart  the  fragments  although  they 
were  fastened  together  only  by  catgut  or  light  silk  sutures.  It  is  plain, 
therefore,  that  a  strong  suture,  one  of  metal  or  heavy  silk,  is  not  neces- 
sary to  the  proper  approximation  of  the  fragments  if  the  joint  is  not 
distended  and  if  the  foot  is  kept  elevated.  Consequently,  any  addi- 
tional risk  or  complexity  of  procedure  involved  in  the  use  of  a  strong 
suture  is  not  justified.  This,  in  my  opinion,  is  sufficient  for  the  rejec- 
tion of  all  methods  of  suturing  which  require  drilling  of  the  bone, 
even  without  consideration  of  the  other  disadvantages  of  a  permanent 
suture  through  it  which  have  been  described  in  Chapter  VII. 

The  remos^al  of  the  effusion  facilitates  approximation,  reduces  ten- 
sion, and  probably  diminishes  the  chance  of  the  formation  of  adhesions 
and  peri-articular  thickening  and  retraction.  Other  things  being  equal, 
therefore,  methods  which  include  such  removal  are  preferable  to  those 
which  do  not,  and  if  they  also  permit  the  adjustment  of  an  interposed 
periosteal  fringe  or  aponeurotic  shred  they  have  an  additional  advan- 
tage. 

The  periosteal  fringe,  long  charged  with  much  of  the  responsibility 
for  failure  of  bony  or  close  fibrous  union,  has  been  shown  l)y  large 

1  Anderson:  Lancet,  July  2,  1892. 

2  In  1834  Dr.  Barton,  of  Philadelphia,  fastened  the  fragments  together  by  a  wire  passed 
through  them  and  knotted  outside  the  skin;  the  patient  died, 


432  FRACTURES. 

experience  with  operative  methods  in  which  it  was  disregarded  to  be 
usually  a  negligible  factor;  that  is,  long  series  of  cases  treated  by  sub- 
cutaneous suture  have  given  close  union  in  almost  all,  and  yet  it  must 
be  believed  that  a  fringe  of  some  size  was  present  in  most  of  them. 
On  the  other  hand,  I  think  the  large  aponeurotic  shreds  which  I  have 
seen  several  times  would  probably  have  been  a  serious  obstacle  if  they 
had  been  left,  and  possibly  similar  ones  have  been  responsible  for  some 
of  the  failures  noted  under  methods  of  treatment  usually  efficient.  It 
is,  therefore,  not  necessary  to  choose  an  open  method  of  operating  in 
order  to  adjust  the  fringe,  but  probably  in  a  small  proportion  of  cases 
there  is  present  a  fringe  or  shred  of  such  size  that  it  will  diminish  the 
success  of  any  operation  which  does  not  effect  its  removal.  Again, 
other  things  being  equal,  an  open  method  better  protects  against  this 
obstacle  to  success. 

Infection  may  occur  in  any  operation  which  wounds  the  skin,  and 
the  chance  of  its  spread  to  the  joint — the  great  danger — is  greater  if 
that  wound  communicates  with  the  joint  or  the  seat  of  fracture.  The 
briefer  the  existence  of  that  wound  or  of  that  connection,  the  less  the 
danger.  All  the  so-called  subcutaneous  methods  require  two  or  more 
small  incisions,  and  in  all  a  suture  of  silk  or  wire  is  passed  either 
directly  into  the  joint  or  through  the  line  of  fracture  or  its  immediate 
neighborhood.  If  suppuration  occurs  at  a  puncture  the  suture  opens 
a  direct  road  for  its  spread  to  the  joint.  The  size  of  the  wound  is  not 
a  measure  of  the  chance  of  infection  ,  that  comes,  if  the  common  pre- 
cautions are  taken,  mainly  from  the  hands  of  the  operator  and  his 
assistants. 

Finally,  the  permanent  presence  in  the  tissues  of  a  foreign  body  is 
not,  according  to  general  experience,  a  matter  of  indifference  ;  occasion- 
ally suppuration  takes  place  about  it  after  a  long  interval,  and  not 
infrequently  its  removal  has  been  required  because  of  pain  and  irrita- 
tion. 

The  operative  methods  are:  (1)  by  open  incision — direct  suture  of 
the  fragments  through  holes  drilled  in  them,  suture  of  the  libro-perios- 
teal  layer  and  capsule,  and  mediate  suture  through  the  tendon  of  the 
quadriceps  and  ligamentum  patellae ;  (2)  subcutaneous  suture — by  wire 
through  the  whole  length  of  the  fragments,  or  by  silk  through  the 
tendons  and  crossing  the  front  of  the  bone  ;  (3)  subcutaneous  permanent 
ligature  surrounding  the  fragments  in  the  sagittal  plane  and  lying 
partly  in  the  joint ;  (4)  temporary  ligatures  passing  through  the  joint 
as  in  (3),  or  through  the  tendons  as  in  (2),  or  through  the  bone,  all  tied 
outside  the  skin. 

The  methods  are  far  too  numerous  to  permit  a  detailed  description 
and  criticism,  even  if  it  were  not  probable  that  most  of  them  will  be 
abandoned  in  favor  of  the  simpler  and  safer  ones.  Many  of  them,  too, 
can  be  judged  in  classes.  Thus,  for  reasons  given  above,  I  would  reject 
all  in  which  a  permanent  suture  is  placed  in  the  bone  itself. 

Temporary  ligature  through  the  tendons  (one  of  the  earliest  methods 
proposed),  or  through  the  bone,  or  around  it  through  tlie  joint  seems 
to  me  to  be  more  dangerous,  because  of  the  prolonged  connnuiiication 
with  the  exterior,  and  less  efficient  than  the  similar  subcutaneous 
methods. 


FRACTURES  OF   THE  PATELLA.  433 

The  subcutaneous  methods  which  can  be  done  equally  well  by  an 
open  incision  appear  to  have  an  equal  risk  with  and  to  lack  the  <\(han- 
tages  which  belong  to  the  latter. 

Barker's  subcutaneous  ligature  about  the  fragments  (silver  or  silk 
passing  through  the  joint)  opens  a  direct  road  for  the  spread  to  the 
joint  of  infection  occurring  at  either  puncture  or  small  incision,  and  as 
it  also  fails  to  provide  for  satisfactory  evacuation  of  the  joint  and 
adjustment  of  the  periosteal  fringe  I  should  reject  it.  It  api)ears  to 
have  met  with  considerable  favor  and  success  since  its  introduction  in 
1894  and  has  been  warmly  commended  by  several. 

My  personal  experience  is  limited  to  the  subcutaneous  mediate  silk 
suture  through  the  tendon  and  the  ligamentum  patellae  (18S9-1S92, 
about  forty  cases)  and  open  incision  with  the  same  or  the  fascial  and 
fibro-periosteal  suture  (1892-1909,  about  two  hundred  and  fifty  cases). 
In  the  first  series  infection  occurred  twice  and  resulted  in  a  stifi"  joint, 
suppuration  appearing  in  one  of  them  after  the  patient  had  left  the 
hospital,  apparently  well,  in  the  second  week.  In  the  second  series  all 
the  cases  have  recovered  without  accident  and  with  close  union,  except 
one  case  of  slight  superficial  suppuration  which  did  no  harm;  all  that  I 
have  seen  after  the  third  month  have  had  good  use  of  tlie  joint  except 
one  very  stout  nervous  woman  who  could  not  be  persuaded  to  abandon 
crutches;  her  patella  was  freely  movable  laterally  and  union  was  close, 
but  flexion  was  limited  to  30  degrees  three  months  nfter  the  accident, 

I  began  with  tiie  subcutaneous  method  because  I  thought  its  risks 
less  than  those  of  free  incision,  but  when  I  found  that  the  extrava- 
sated  blood  often  escaped  freely  through  some  of  the  four  small  incis- 
ions and  that  consequently  the  suture  lay  free  within  the  area  of 
fracture  and  laceration  I  abandoned  it  for  the  single  free  incision  and 
was  soon  convinced  that  the  patient  was  equally,  perhaps  better,  pro- 
tected. A  special  advantage  of  the  latter  method  is  that  the  operation 
can  be  done  without  once  touching  the  cut  tissues  with  the  fingers,  and 
to  that  I  attribute  the  complete  freedom  from  infection.  I  have 
frequently  done  the  operation  under  local  anaesthesia — cocaine  or 
freezing. 

The  method  is  as  follows  :  The  surface  having  been  ])reparc'd,  an 
incision  is  made  in  the  median  line  slightly  overlai>])ing  the  two  frag- 
ments ;  the  sides  are  drawn  apart,  the  fragments  lifted  in  turn  with  a 
sharp  retractor,  and  their  surfaces  freed  from  clot  or  fringe  ;  while 
they  are  held  up  the  joint  is  thoroughly  washed  with  a  hot  sterile  salt 
solution.  A  stout  chromic  catgut  ligature  is  passed  through  the  lateral 
expansion  and  capsule  close  to  the  bone  on  each  side;  these  are  tied 
wliile  the  fragments  are  held  in  exact  api)ositiou,  and  tlicn  the  fibro- 
periosteum  and  other  superficial  layers  adjusted  and  fastened  with 
catgut.  The  incision  is  closed  wn'thout  drainage  with  an  uninterrupted 
silk  suture,  the  dressing  applied,  and  the  limb  bound  ui)on  a  ])osterior 
splint.  The  patient  is  ke])t  in  bed  with  tiie  foot  elevated  for  a  week, 
the  silk  suture  of  the  incision  is  then  removed,  and  a  liglit  i)lastcr-of- 
Paris  encasement  applied.  After  a  few  days  the  ]:»aticnt  leaves  the 
hospital  on  crutches,  and  after  a  month  the  dressing  is  cut  (h)wn  the 
middle  in  front,  and  he  is  directed  to  wear  it  onl\-  in  the  (la,\time. 
31 


434 


FRACTURES. 


Usually  the  joint  can  be  flexed  at  least  90  degrees  by  the  end  of  the 
third  month,  often  earlier,  and  the  patient  usually  discards  the  splint 


Fig.  310. 


Fracture  of  patella,  five  months  old  ;  after  treatment  by  straight  splint.   Active  extension  a'lmost 

complete. 

Fig. 311. 


Fracture  of  patella  ;  two  years  after  mediate  suture. 


FRACTURES  OF  THE  PATELLA. 
Fig.  312. 


435 


Fracture  of  patella;  three  years  after  periosteal  suture. 
Fm.  313. 


Patella;  tliree  months  after  periosteal  suture  ol  iVacture. 


436  o*  FRACTURES. 

entirely  before  that  time,  since  he  is  told  it  serves  only  as  a  protection 
against  damage  by  a  fall.  In  no  case  have  I  seen  the  fragments  separate 
under  use,  but  several  have  come  back  in  the  third  or  fourth  month 
with  a  fracture  caused  by  a  fall. 

I  have  thrice  used  a  transverse  incision  ;  it  permits  more  exact  suturing 
of  the  rents  in  the  lateral  expansions,  but  I  prefer  the  median  incision. 

1  have  treated  a  few  cases  without  immobilization  after  the  tenth 
dav,  but  the  gain  in  rapidity  of  restoration  of  function  has  not  been 
sufficient  to  justify  the  risk  of  accident. 

For  Ceci's^  method,  first  subcutaneous  wire  suture  through  bone; 
Aiken's  ^  modification,  the  wire  passing  only  once  through  the  bone  and 
then  back  under  the  skin  ;  Barker's  ^  method,  subcutaneous  ligature 
through  the  joint  about  the  patella  ;  my  earlier  method,*  subcutaneous 
mediate  suture  through  the  tendon  and  ligamentum,  the  reader  is  re- 
ferred to  the  original  accounts.  Other  plans  not  above  mentioned  are 
those  of  Wolff/'  open  incision,  two  metal  rivets  driven  into  each  frag- 
ment to  receive  silver  wires  by  which  the  fragments  are  fastened 
together ;  Kittredge,®  two  similar  rivets  placed  astride  the  line  of  frac- 
ture ;  and  Axford,'^  temporary  wire  suture  through  the  bone  and  back 
outside  the  skin.  Other  older  temporary  measures  are  Barton's  (1834, 
the  same  as  Axford's),  Volkmann's  silk  loops  transversely  through  the 
tendon  and  ligamentum  patellse  and  tied  together  over  the  skin,  and 
Kocher's  (1 880)  surrounding  wire  ligature,  passing  like  Barker's  through 
the  joint  beneath  the  patella  but,  unlike  his,  including  the  skin  in  its 
loop. 

Compound  fractures  sj)ecially  need  protection  from  infection  be- 
cause of  the  importance  of  the  joint  and  the  danger  to  life  or  limb 
involved  in  its  suppuration.  If  infection  has  already  occurred  the 
joint  must  be  cleaned  as  thoroughly  as  possible  and  drainage  provided 
on  each  side.     The  fragments  must  be  sutured  together. 

Disability  After  Fracture.  This  may  be  due  to  stiffness  of  the 
joint  or,  much  less  frequently,  to  the  loss  of  active  extension.  The 
causes  of  the  former  are  varied,  and  but  few  of  those  which  are  per- 
manent, which  do  not  gradually  diminish  under  use,  can  be  removed 
by  operation.  Many  attempts  to  relieve  have  been  made  upon  the 
theory  that  the  fault  lay  in  separation  of  the  fragments  or  in  the 
absence  of  a  firm  bond  between  them,  the  usual  plan  being  to  open 
the  joint  and  bring  the  fragments  together.  Failures  have  been  numer- 
ous, either  through  inability  to  close  the  gap,  or  through  infection,  or 
through  persistence  of  the  disability  after  an  operative  success.  Even 
in  many  of  the  cases  in  which  improvement  has  followed  the  operation 
it  seems  probable  that  an  equal  improvement  would  have  come  in  time 
without  the  aid  of  the  interference.     Chaput,^    who  has    thoroughly 

^  Ceci :  Deutsche  Zeitschrift  fiir  Chirurgie,  February,  1888. 

2  Aiken  :  British  Medical  Journal,  July  23,  1892. 

3  Barker  :  Lancet,  April  18,  1896,  and  American  Text-book  of  Surgery,  1897. 

*  Stimson :  New  York  Medical  Journal,  May  10,  1890,  p.  531,  and  American  Text- 
book of  Surgery,  1892. 

5  WolflF:  Deutsche  med.  Wochenschrift,  May  14,  1S9I. 

6  Kittredge:  Boston  Medical  and  Surgical  Journal,  November  19,  1891. 
T  Axford :  Annales  of  Surgery,  July,  1898. 

^Chaput:  Fractures  anciennes  de  la  Kotgale.  These  de  Paris,  1885,  and  La  Semaine 
Medicale,  June  17,  189X. 


PllACTlfBES  OF  THE  PATELLA.  437 

studied  the  conditions,  attributes  the  loss  of  flexion  to  hypertrophy  or 
rigid  elongation  of  the  united  patella  by  which  it  is  made  too  lono-  to 
pass  around  the  condyles,  or,  much  more  frequently,  to  the  ascen?  of 
the  upper  fragment  (with  a  separation  of  two  to  five  centimetres),  in 
consequence  of  which  the  upper  portion  of  the  capsule  and  the  lateral 
expansions  become  so  shortened  that  the  descent  of  the  fragment  is 
impossible,  and  it  cannot  be  sufficiently  mobilized  without  a  division 
of  its  attachments  too  extensive  to  bo  practicable  or  perhaps  compatible 
with  its  vitality ;  and  even  if  the  lower  fragment  is  brought  up  to  the 
upper  one  by  detachment  of  the  ligamentum  ])atell8e  from  the  tibia 
(Von  Bergmann,  1887)  and  is  united  with  it  flexion  Avould  still  be  lost. 
This  being  so,  what  is  required  is  not  the  approximation  or  reunion  of 
the  fragments  but  the  removal  of  the  obstacle  to  the  descent  of  the 
upper  one.  Chaput  did  this  in  one  case  by  excising  the  upper  fragment 
and  obtained  a  good  result,  the  patient  being  able  to  walk  up  and  down 
stairs  and  carry  a  burden  of  200  {)ounds  ;  the  range  of  motion  is  not 
stated.  His  grouping  of  the  different  forms  and  their  respective  treat- 
ment is  as  follows  : 

1.  Close  union.     Medical  treatment  and  exercise. 

2.  Elongation  of  the  patella  by  hypertrophy  or  a  stiff  bond  with  loss 
of  flexion.     Extirpation  of  the  patella. 

3.  Short  flexible  bond.     Massage. 

4.  Bond  two  to  five  centimetres  long  with  loss  of  flexion.  Extir- 
pation of  upper  fragment. 

5.  Bonds  more  than  five  centimetres  long,  and  those  cases  of  class 
4  in  wliich  active  extension  is  lost.  Suture  of  the  fragments  after  free 
separation  of  the  lower  portion  of  the  quadriceps  and  u])per  part  of  the 
capsule  from  the  femur.  This  denudation  of  the  femur  he  proposes  to 
effect  through  a  curved  transverse  incision  at  the  level  of  the  lower 
fragment  or,  if  the  gap  is  long,  through  a  longitudinal  one  ;  for  the 
denudation  he  would  use  the  elevator  or  knife  and  would  suture  the 
fragments  with  wire  because  the  strain  might  be  too  great  for  periosteal 
sutures. 

Rupture  of  Bond  ("Refracture").  As  this  is  caused  by  the  tearing 
away  of  the  lower  fragment  from  the  upper  one  in  forcible  flexion,  full 
extension  of  the  joint  brings  the  torn  surfaces  into  contact,  and  we 
have  only  to  wait  for  them  to  reunite,  opposing  swelling,  if  necessary, 
by  appropriate  measures.  Once  or  twice  I  have  reopened  the  joint 
and  again  sutured  the  fragments,  and,  of  course,  this  would  be  done  if 
the  fracture  is  compound.  The  prognosis  is  made  worse  by  the  pro- 
longation of  the  confinement  and  the  repetition  of  the  trauma  and  its 
consequences. 

Rogers  {Annals  of  Surg.,  April,  1914,  p.  483)  got  good  results  in  two 
cases  by  a  bone  inlay.  Schanz^  obtained  a  good  functional  result  in  a 
fracture  five  years  old  with  a  separation  of  tweh'c  centimetres.  Through 
an  incision  on  the  inner  side  from  below-  the  knee  to  the  middle  of  the 
thigh,  over  the  sartorius,  this  muscle  was  mobihzed  and  secured  by 
wire  sutures  upon  the  front  of  the  fragments.  Six  weeks  after  operation 
the  patient  could  run  upstairs. 

1  Scluuiz:  Beilage  zum  Cent.nilblatt  fur  Chir.,  19();5,  p.  157. 


CHAPTER  XXV. 

FEACTUEES  OF  THE  BONES  OF  THE  LEG. 

Of  the  upper  end  of  tibia  or  both,  separation  of  epiphysis  of  the  tibia,  avulsion 
of  the  spine,  avulsion  of  the  tubercle — Of  the  shaft  of  the  tibia  or  both — 
At  the  lower  end :  Comminuted,  supramalleolar,  separation  of  epiphysis  of 
tibia,  by  eversion  and  abduction  (Potts),  by  inversion',  of  the  posterior  portion 
of  the  tibia — Of  the  fibula:  Upper  end,  shaft,  separation  of  epiphysis. 

According  to  the  table  in  Chapter  I.  fractures  of  the  haft  of  the 
tibia  or  of  both  bones  constitute  one-fourth  of  those  of  the  lower  ex- 
tremity, and  more  than  6  per  cent,  of  all  fractures.  The  more  fre- 
quent seat  is  at  or  near  the  junction  of  the  lower  and  middle  thirds. 
When  both  bones  are  broken  the  fibula  is  usually  broken  at  a  higher 
level  than  the  tibia.  - 

Statistics  show  that  infancy  and  childhood  are  almost  exempt,  and 
that  the  maximum  of  frequency  is  found  between  the  ages  of  thirty 
and  sixty  years,  those  three  decades,  according  to  Malgaigne,  furnish- 
ing equal  numbers. 

1.  FRACTURES  OF  THE  UPPER  END  OF  THE  TIBIA  AND  FIBULA 
OR  OF  THE  TIBIA  ALONE.^ 

The  causes  of  these  fractures  are  direct  and  indirect  violence ;  in  the 
former  a  blow  received  directly  upon  the  part,  as  the  fall  of  a  heavy 
body  or  the  kick  of  a  liorse ;  in  the  latter  a  fall  from  a  height  or  a 
twist  of  the  limb,  especially  abduction. 

The  line  of  fracture  may  be  transverse,  oblique,  or  longitudinal,  in 
the  latter  cases  passing  into  the  joint  and  separating  only  a  portion  of 
the  articular  end  from  the  shaft,  or  there  may  be  a  crush  of  either  tuber- 
osity of  the  tibia. 

In  the  mechanism  of  the  production  of  these  fractures  two  fac- 
tors appear  to  take  the  principal  part,  either  alone  or,  more  fre- 
quently, in  varying  degrees  of  combination,  namely,  the  weight  of 
the  body  and  lateral  flexion  of  the  leg  upon  the  thigh.  They  are 
brought  into  action  by  a  fall  upon  the  foot  or  by  lateral  pressure 
against  the  knee,  usually  while  the  foot  rests  upon  the  ground  and 
bears  the  weight  of  the  body.  If  the  weight  of  the  body  is  the  sole 
or  main  factor,  the  upper  end  of  the  tibia  may  be  split  into  several 
fragments,  between  which  the  adjoining  portion  of  the  shaft  is  forced, 
the  "  compression  fracture  "  of  Wagner.  If  the  mechanical  conditions 
vary  slightly,  so  that  the  force  is  exerted  mainly  on  one  tuberosity,  that 
tuberosity  alone  is  broken  off  and  either  is  forced  directly  downward 

'  Including  separation  of  the  upper  tibial  epiphysis  and  avulsion  of  the  tubercle  of  the 
tibia. 

(438) 


PRACTURES  OF  THE  BONES  OF  THE  LEG. 


m 


or  is  tilted  to  one  side.  If  forcible  lateral  pressure  at  the  knee — lateral 
bending  of  the  limb — is  the  main  factor,  combined  with  some  down- 
ward pressure,  a  condition  closely  resembling  the  preceding  may  be 
produced,  together  with  fracture  of  the  fibula  close  below  its  head  ; 
that  is,  one  or  both  tuberosities  are  broken  off  from  the  sliaft  and  from 
each  other,  and  the  diaphysis  penetrates  somewhat  into  them.  Thus, 
Fig.  317  represents  a  fracture  caused  by  collision  with  an  automobile 
while  the  patient  was  walking,  the  blow  being  received  against  the 
outer  side  of  the  knee  and  probably  causing  forced  abduction  of  the 
leg.  In  another  case  the  condition  was  caused  while  the  patient  was 
seated,  and  therefore,  presumably,  by  abduction  alone.  The  specimen 
represented  in  Fig.  314  suggests  that  the  same  mechanism  may  produce 
a  transverse  fracture  of  both  bones  without  splitting  of  the  head.  An 
alternative  lesion,  under  the  action  of  these  forces,  is  the  breaking  of 
the  condyles  of  the  femur  by  upward  pressure  or  by  avulsion. 


Fig.  314. 


Fig.  315. 


Fig.  316. 


Fractureof  the  head  of  the  tibia  Fracture  of  external  tuberosity 
with  impaction  and  separation  of  of  tibia  by  compression  in  abduc- 
the  upper  fragments.  tion. 

Of  longitudinal  fracture  I  have  seen  one  case,  a 
man  of  twenty-five  years.  The  line  of  fracture  ran 
from  the  inner  part  of  the  outer  articular  surface 
directly  downward  in  a  sagittal  plane.  The  sepa- 
ration at  the  upper  end  was  about  half  an  inch  and 
was  maintained  partly  by  a  small  fragment  lodged 
deeply  in  the  cleft,  but  even  after  removal  of  the 
latter  the  displacement  could  not  be  wholly  reduced.  The  cause  was  a 
fall  from  a  ladder,  but  the  mechanism  was  not  known.  The  joint  was 
so  loosened  that  the  tibia  could  be  moved  outward  nearly  half  an  inch. 
Recovery  took  place  with  active  flexion  nearly  to  a  right  angle  and 
marked  genu  valgum. 

The  displacement  varies  with  the  character  of  the  fracture  and  the 
fracturing  force  :  in  a  transverse  fracture  without  comminution  it  is 


Fracture  of  upper  ends 
of  both  bones. 


440 


FRACTURES. 


usually  slight ;  in  comminution  of  the  upper  end  and  in  oblique  frac- 
ture of  either  tuberosity  the  fragment  may  be  notably  displaced  or 
tilted.  The  direct  or  indirect  implication  of  the  joint  ensures  an  effu- 
sion within  it,  and  the  proximity  of  the  main  vessels  makes  their  injury 
more  likely  than  in  fracture  at  most  other  points.  Both  tibial  arteries 
and  the  pophteal  vein  have  been  torn,  the  injury  in  every  case  leading 
to  amputation  or  death. 

Diagnosis.     The  diagnosis,  in  reaching  which  the  aid  of  an  anaesthetic 
may  be  required,  is  made  by  recognition  of  the  irregularity  of  outline, 

Fig.  317. 


Fracture  of  upper  end  of  tibia  and  fibula  mainly  by  forced  abduction  of  leg  ;  x-ray  tracing. 


pain  on  local  pressure  and  on  pressing  the  leg  upward,  and  possibly 
abnormal  mobility  and  crepitus.  In  high  transverse  fractures  care 
must  be  taken  not  to  mistake  the  injury  for  a  subluxation  of  the  knee. 
Prognosis.  Tlie  prognosis  of  this  injury  is  exceptionally  serious, 
because  of  the  proximity  of  the  joint  and  the  possibility  of  inflamma- 
tory complications  and  the  more  or  less  complete  loss  of  the  functions 
of  the  knee  which  that  and  the  derangement  of  the  articular  surface  in 
oblique  and   comminuted   fractures  involve,  and   also  because  of  the 


PLATE  XXV 


Fracture  of  the  Upper  End  of  Tibia  by  Abduction  of  the  Leg. 


FRACTURES  OF  THE  BONES  OF  THE  LEG.  441 

exceptionally  long  period  that  is  necessary  for  consolidation.  The 
average  period  in  seven  cases  collected  by  Poncet  was  about  tour 
months.  No  satisfactory  explanation  has  been  given  of  this  peculiaritv. 
Treatment.  Displacement  must  be  corrected  by  traction  and  direct 
pressure  according  to  its  character,  and  retention  effected  either  by 
permanent  traction  or  by  a  suspended  posterior  splint  with  the  knee 
partly  flexed  or  by  encasement  of  the  entire  limb  in  plaster.      The 

Fig.  318. 


Fracture  of  external  tuberosity  of  tibia  ;  a;-ray  tracing,  probably  by  abduction. 

indications  vary  so  much  with  the  position,  direction,  and  extent  of 
the  fracture  that  general  rules  cannot  well  be  made.  Complete  encase- 
ment is  valuable  to  prevent  bowing  of  the  knee  when  the  fracture 
extends  into  the  joint. 

When  the  fracture  extends  into  the  joint  function  may  be  so  limited 
by  an  irregular  position  of  the  articular  fragments  tliat  it  may  be  wise 
to  expose  them  by  incision  for  more  accurate  adjustment. 

If  the  fracture  is  compound  and  if  suppuration  of  the  joint  occurs, 
a  free  outlet  for  the  pus  must  be  promptly  pro\'ided  by  special  open- 
ings at  the  sides  rather  than  through  the  wound  which  can  hardly  fail 
to  be  unsuitably  placed  for  effective  drainage. 


442 


FRACTURES. 


Separation  of  the  Epiphysis. 

has  been  noted  in  a  few  cases.  Bruns  collected  four,  Hutchinson^  says 
he  has  records  of  ten,  including  three  unpublished  cases,  and  Poland^ 
collected  twenty-four.  Other  reported  cases  that  I  have  seen  are 
those  of  Heuston  and  Manly .^  In  Hutchinson's  list  the  extremes 
of  age  were  one  and  sixteen  years.  The  common  cause  appears  to  be 
a  wrench  of  the  leg,  abduction  or  adduction,  by  which  a  transverse 
strain  is  made,  but  Poland  thinks  it  is  direct  pressure  against  the 

Fig.  319. 


Fracture  of  the  upper  end  of  the  tibia  aud  fibula. 

epiphysis.  Oneof  Poland's  was  compound;  the  patient  recovered.  In 
twelve  the  patient  died  or  the  limb  was  amputated.  The  ages  ranged 
from  three  to  twenty  years.  In  all  but  one  case  the  process  bearing  the 
tubercle  of  the  tibia  accompanied  the  epiphysis.  The  displacement  was 
forward,  forward  and  outward,  or  lateral,  and  usually  slight.  In  a 
number  the  diaphysis  was  also  broken,  and  sometimes  extensively.  In 
several  of  the  cases  which  recovered  no  trace  remained  of  the  injury. 


1  Hutchinson:  British  Medical  Journal,  March  31,  1894. 

2  Poland:  Traumatic  Separation  of  the  Epiphyses,  p.  802. 

3  Heuston  and  Manly:  British  Medical  Journal,  July  21  and  September  22,  1888. 


FRACTURES  OF   THE  BONES  OF  THE  LEG.  443 

Fracture  of  the  Spine  of  the  Tibia. 

Previous  to  the  introduction  of  the  .r-rays  this  injury  was  known 
only  as  a  complication  of  dislocation  of  the  knee,  produced  by  traction 
through  the  crucial  ligament.  Recently  several  cases  have  been  recog- 
nized by  the  aid  of  the  .r-rays  in  much  slighter  injuries  of  the  joint, 
so-called  sprains  or  twists,  and  the  subject  has  been  studied  in  detail 
by  Pringle,^  Goetze,^  and  Jones  and  Smith.^  According  to  the  latter, 
the  injury  seems  more  frequently  to  be  caused  by  pressure  of  the  edge 
of  the  external  condyle  against  the  spine  than  by  a\'ulsion.  The  most 
definite  symptom  is  inability  fully  to  extend  the  knee.  The  treatment 
is  forced  full  extension  when  possible,  followed  by  immobilization  in 
full  extension  for  three  or  four  weeks.  If  operation  is  done  the  pref- 
erable route  is  from  in  front  with  longitudinal  division  of  the  patella 
and  its  ligament. 

Avulsion  of  the  Tubercle  of  the  Tibia. 

To  the  tubercle  is  attached  the  ligamentum  patellae,  and  all  but  one 
of  the  cases  of  fracture  which  have  been  reported  have  been  caused  by 
the  action  of  the  quadriceps  in  some  violent  effort,  usually  jumping, 
and  most  of  them  in  youths  between  twelve  and  eighteen  years  of  age. 
Overlook^  reported  a  case  in  which  the  fracture  was  caused  by  direct 
violence,  the  kick  of  a  horse.  The  frequency  in  youth  is  to  be  ac- 
counted for  by  the  fact  that  the  tuberosity  is  a  downward  prolongation 
of  the  epiphysis  and  remains  separated  from  the  shaft  by  conjugal 
cartilage  until  growth  is  completed.  Miiller,^  who  wrote  the  first  special 
article  upon  the  subject,  collected  seven  cases  and  added  one  of  his  own. 
Other  formal  papers  are  by  Schlatter,^  Osgood,^  Keyser,^  Landsberg,^ 
Ware,^"  Gaudier  and  Bouret,^^  and  Linkenheld,^^  who  collected  twenty- 
seven  cases.  The  size  of  the  fragment  has  varied  in  length  from  two 
to  five  centimetres,  being  smaller  in  the  young  than  in  adults,  and  in 
one  exceptional  case  (Richet)  the  rupture  ran  partly  through  the 
tubercles  (both  legs)  and  partly  through  the  ligamentum  patella?. 
The  fragment  is  sometimes  displaced  upward  and  sometimes  rotated 
forward  on  its  upper  edge. 

Symptoms.  The  symptoms  are  inability  to  use  the  limb  immediately 
following  the  effort,  which  sometimes  is  accompanied  by  a  cracking 
sound,  and  the  recognition  of  a  movable  lump  of  bone  about  two  inches 
below  the  patella.  On  pressing  this  lump  downward  and  backward 
against  the  tibia  crepitus  is  felt.  The  knee-joint  is  more  or  less  dis- 
tended by  an  effusion. 

1  Pringle:  Annals  of  Surg.,  vol.  46,  p.  169. 

2  Goetze:  Ztlblatt.  fur  Chir.,  vol.  12.3,  p.  221. 

'  Jones  and  Smith:  Brit.  .Journ.  Surg.,  .Julv,  191.3,  p.  70. 

4  Overlook:  Conn.   State   Mod.   Sof.,    1907,   p.   2.S.S. 

5  Miiller:  Beitrilge  zur  klin.  Chir.,  November,   1S87,  p.  2.57. 
f' Schlatter:  Ilnd.,   1903,  vol.  xxxviii,  p.  S74. 

''  Osgood:   Boston  Medical  and  Surgical  .lournal,  1903,  vol.  cxlviii,  p.  114. 

•*  Keyser:   Reported  in  Sajous's  .\iinual,  ISSS,  vol.  ii,  p.  267. 

»  Landsberg:   Cent ralhlat  I    liirChir.,  .Septcinlier  2S,    IS.SO. 
'"  Ware:  Annals  of  Surger.\-,  Xoveinher,  li>04,  p.  739. 
"  Gaudier  and  Bouret:   Revue  de  Chir.,  vol.  32,  p.  30.'5. 
'2  Linkenheld:  Deutsche  Zeitschrift  fiir  Chir.,  vol.  87,  p.  220. 


444 


FRACTURES. 


It  seems  to  me  that  skiagraphic  appearances — the  existence  of  a 
clear  Hne  between  the  tubercle  and  the  shaft — have  led  of  late  to  the 
diagnosis  of  fracture  in  some  of  the  common  cases  of  slight  injury 
which  do  not  deserve  to  be  thus  classed.  Thus,  Schlatter,  who  claims 
seven  cases  in  less  than  three  years,  includes  those  in  which  there  was 
no  sudden  onset,  no  disability,  no  symptom  except  tenderness  on  press- 
ure, cases,  it  seems  to  me,  of  slight  ruptures  of  the  periosteum  or 
conjugal  cartilage  or  even  of  exaggerated  nutritive  activity.  I  have 
seen  a  lump  slowly  form  at  the  site  of  the  tubercle  in  such  cases.  (See 
also  Winslow,  Annals  of  Surg.,  Feb.,  1905,  Alsberg,  Zeitschft.  fiir  Orth. 
Chir.,  vol.  20,  and  Ebbinghaus,  Deutsch.  Med.  Wochshft,  1913,  Xo.  34. 

Treatment.  The  treatment  is  to  press  the  fragment  into  place  and 
maintain  it  there  by  a  bandage  or  strips  of  adhesive  plaster  while  the 
limb  is  kept  extended  upon  a  splint  for  four  or  five  weeks.  In  a  few 
cases  the  fragment  has  been  exposed  by  incision  and  secured  in  place 
with  periosteal  sutures  or  even  by  temporary  nailing. 

The  ultimate  result  has  been  good  in  all  the  cases,  but  in  one  the 
restoration  of  motion  was  not  complete  until  after  a  year. 


2.  FRACTURES  OF  THE  SHAFT. 

Fractures  by  direct  violence  may  occur  at  any  point ;  those  by  indi- 
rect violence  are  much   more   frequent  at  or   near  the  junction  of  the 
lower  and  middle  thirds  than  at  any  other  point.     It  seems  probable, 
as  taught  more  especially  by  Gosselin,  that  torsion  of  the  limb  is  an 
important  factor  in  the  production  of  the  fracture,  the 
Fig.  320.       twist  being  due  either  to  the  forcible  contraction  of  the 
muscles  or  to  the  propulsion  of  the  upper  portion  while 
the  lower  one  is  fixed  by  the  pressure  of  the  foot  upon 
the  ground. 

The  varieties  of  fracture  common  to  other  long  bones 
are  found  here,  and  in  addition  a  form  of  spiral,  the 
V-shaped  fracture,  first  pointed  out  by  Gosseliu,  which 
although  occasionally  found  elsewhere  is  much  more  fre- 
quent in  the  leg.  In  these,  which  are  especially  frequent 
below  the  middle  of  the  bone,  the  upper  fragment  termi- 
nates in  front  and  on  the  inner  side  in  a  more  or  less 
sharp  triaugular  point,  the  lower  fragment  presents  a 
similar  point  posteriorly,  and  from  the  bottom  of  the  de- 
pression in  the  lower  fragment  which  corresponds  to  the 
first  point  a  fissure  passes  spirally  downward,  and  usually 
runs  into  the  ankle-joint,  sometimes  splitting  off  a  super- 
ficial fragment  on  the  posterior  aspect,  as  shown  in  Fig. 
320.  The  extent  of  the  fissures  and  the  implication  of 
the  ankle-joint  give  this  variety  of  fracture  an  especial 
importance. 

It  is  uncommon  for  the  tibia  alone  to  be  broken  when 
V-shaped fractuie.  the  fracture  is  by  indirect  violence,  for  the  force  con- 
tinues to  act,  if  only  for  a  moment,  and  breaks   the 


FRACTURES  OF   THE  BONES  OF   THE  LEG.  445 

weaker  fibula  all  the  more  easily,  and  usually  at  a  higher  point  than 
the  tibia. 

The  subcutaneous  position  of  the  tibia  throughout  its  entire  length 
greatly  exposes  its  fractures  to  the  chance  of  becoming  compound  either 
by  the  direct  action  of  the  causative  violence  when  the  fracture  is  direct, 
or  by  the  perforation  of  the  skin  by  the  end  of  one  of  the  fragments, 
usually  the  upper  one,  when  the  fracture  is  indirect. 

The  displacements  show  the  usual  varieties,  but  the  most  common 
and  important  is  the  projection  of  the  lower  end  of  the  upper  fragment 
when  it  terminates  in  an  anterior  point,  as  it  usually  does,  the  con- 
traction of  the  predominant  muscles  of  the  calf  aiding  it  by  creating 
an  anterior  angular  displacement. 

In  addition  to  the  usual  symptoms  of  crepitus,  abnormal  mobility, 
pain,  and  loss  of  function,  there  is  also  the  irregularity  in  the  outline 
of  the  subcutaneous  portion  of  the  tibia  which  may  be  recognized  by 
passing  the  finger  along  it.  It  is  not  always  possible  to  say  whether  or 
not  the  fibula  is  broken  as  well  as  the  tibia  without  making  a  more 
severe  and  ])ainful  examination  than  the  need  of  the  information  will 
justify.  When  both  bones  are  broken  the  mobility  is  usually  much 
greater  than  when  the  tibia  alone  is  broken,  and  by  making  gentle 
pressure  with  the  finger  along  the  line  of  the  fibula  the  point  of  frac- 
ture can  usually  be  determined. 

Beside  the  frequent  complication  of  a  communicating  wound  of 
the  skin,  and  the  comminution  which  is  so  often  the  result  of  direct 
violence,  injury  to  the  principal  vessels  is  occasionally  met  with. 
Nepveu,^  in  a  very  complete  and  elaborate  paper  read  before  the 
Surgical  Society  of  Paris,  collected  more  than  fifty  cases,  among  which 
are  found  examples  of  injury  to  both  tibials,  the  peroneal,  and  the 
nutrient  artery  of  the  tibia.  Injury  to  the  tibial  or  peroneal  nerves 
seems  to  be  much  more  rare.  JVIourret  collected  twenty-seven  cases 
of  aneurism  complicating  fracture,  five  of  which  were  mistaken  for 
abscess  and  opened. 

I  have  seen  hemorrhage  occur  from  the  anterior  tibial  on  the  eighth 
day  after  fracture  by  direct  violence  without  displacement ;  the  rupture 
was  one  and  a  quarter  inches  above  the  fracture  and  was  evidently  due 
to  bruising  of  the  artery  by  the  wheel  which  caused  the  fracture. 

A  simple  fracture  without  persistent  displacement  will  usually  become 
firmly  consolidated  in  six  weeks  ;  but  in  the  comminuted  ones  and  in 
those  that  are  oblique  with  persistent  displacement  the  callus  remains 
weak  much  longer.  Complete  recovery  is  long  delayed  by  rigidity  at 
the  ankle,  tenderness  of  the  skin,  feebleness  of  the  circulation,  and 
neuralgic  pains  which  are  more  common  after  fractures  of  the  leg  tlian 
after  those  of  other  long  bones.  In  the  old  and  rheumatic  this  delay 
is  especially  prolonged. 

If  the  suppuration  becomes  free  after  a  com])()und  fracture  it  is  prob- 
able that  complete  recovery  will  ])g  postponed  for  even  a  mucli  longer 
time,  and  that  sinuses  leading  down  to  bare  or  necrosed  l)one  will  re- 
main open  for  many  months  or  will  rco))en  at  intervals.  On  the  other 
hand,  the  subcutaneous  position  of  the  tibia  makes  it  easier  to  drain  the 

'  Nepveu:  Bulletins  de  la  SoHete  de  Chirurgie,  1.S75,  p.  365, 


446  FRACTURES. 

cavity  of  the  fracture  thoroughly  and  to  remove  splinters,  and  thus 
makes  the  danger  to  life  less  than  after  compound  fracture  of  bones  that 
are  more  deeply  placed. 

Treatment.  Reduction  of  the  displacement  can  generally  be  made 
by  traction  at  the  foot  and  counter-extension  at  the  knee,  this  joint 
being  slightly  flexed  to  relax  the  muscles  of  the  calf.  In  the  more 
difficult  cases  in  which  spasm  of  the  muscles  opposes  reduction  com- 
pression of  the;  femoral  artery  for  a  few  minutes,  as  suggested  by 
Broca,  has  sometimes  seemed  to  be  useful  in  my  experience. 

^Maintenance  of  the  reduction  depends  largely  upon  the  character  of 
the  fracture;  when  this  is  nearly  transverse  and  toothed,  the  displace- 
ment is  unlikely  to  recur;  but  when  it  is  oblique  the  difficulties  of 
complete  retention  may  be  great.  The  segment  of  the  limb  below  the 
fracture  is  often  too  short  to  permit  traction  by  strips  of  adhesive 
plaster,  as  in  fracture  of  the  thigh,  and  the  surgeon  has  to  depend 
upon  some  form  of  splint  or  an  immovable  dressing,  neither  of  which 
will  certainly  prevent  shortening,  although  the  amount  may  be  so  slight 
as  to  be  without  practical  importance. 

The  usual  routine  of  treatment  in  simple  fractures  without  marked 
displacement  is  to  put  the  patient  in  bed  with  the  limb  in  a  Yolkmann 
splint  (Fig.  40)  for  about  a  week  or  until  the  swelling  has  subsided, 
and  then  to  encase  it  in  plaster  of  Paris.  Under  the  prolonged  use 
of  the  Yolkmann  splint  some  shortening,  usually  slight,  is  likely  to 
occur.  Immediate  application  of  plaster  is  objectionable  because  either 
the  swelling  is  likely  to  increase  and  make  the  dressing  too  tight,  or  it 
will  diminish  and  leave  it  too  loose.  The  stocking  bivalve  plaster 
splint  (Fig.  50)  is  a  convenient  means  of  combining  the  advantages 
of  the  primary  Yolkmann  splint  and  the  later  encasement.  The 
details  of  its  construction  are  given  on  page  100.  ]\Ioulded  plaster 
splints,  anterior  and  posterior,  bilateral,  or  like  those  shown  in  Figs. 
342  and  343,  will  in  many  cases  meet  all  the  indications  satisfactorily 
from  the  beginning.  Care  must  be  taken  to  maintain  full  length  of  the 
leg  and  to  avoid  angular  or  rotatory  displacement  during  the  harden- 
ing of  the  plaster.  Two  angular  displacements  are  specially  liable 
to  occur :  a  lateral  one,  apex  inward,  by  erroneous  correction  of  the 
apparent  normal  curvature  in  the  opposite  direction;  and  an  antero- 
posterior one,  by  dropping  or  elevation  of  the  heel  respectively.  The 
plaster  stocking  or  moulded  splints,  applied  while  the  injury  is  recent, 
and  loosened  or  tightened  as  the  need  arises,  permit  easy  inspection 
to  detect  and  correct  such  displacemcDts  as  may  occiu".  They  also 
permit  massage  and  the  application  and  change  of  such  dressmgs  as 
may  be  needed  for  associated  wouDds  of  the  skin  or  for  blisters. 

If  union  is  delayed  beyond  five  or  six  weeks  it  is  well  to  let  the 
patient  bear  part  of  his  weight  upon  the  foot  in  walking,  angular  dis- 
placement thereby  being  prevented  by  a  strong  plaster  encasement 
or  moulded  splints. 

If  firm,  prolonged  traction  is  required  to  correct  the  displacement  it 
can  be  conveniently  made,  as  shown  in  Fig.  :^>21 ;  plaster  splints  can  be 
applied  and  allowed  to  harden  while  the  traction  is  maintained. 


FRACTURES  OF   THE  BONES  OF   THE  LEG.  447 

In  compound  fracture  the  bivalve  or  fenestrated  or  interrupted 
splint  may  be  used,  or  anterior  and  posterior  moulded  splints,  one  of 
which  holds  the  fragment  in  place  while  the  other  is  removed  that  the 
dressing  may  be  changed.  The  limb  should  be  kept  at  a  level  several 
inches  above  that  of  the  hip,  and  if  interrupted  plaster  splints  are  used 
care  must  be  taken  that  the  upper  portion  does  not  become  too  tight. 
Firm  pressure  upon  the  tissues  in  the  interval  must  be  made  by  snug 
bandaging.  The  details  of  treatment  of  the  wound  are  here  of  special 
importance,  and  particularly  the  distinction  to  be  made  between  frac- 
tures that  are  compound  by  direct  violence  and  those  by  indirect  vio- 
lence. For  these  and  for  ambulatory  treatment  the  reader  is  referred  to 
Chapter  VII. 

Ftg.  321. 


Making  forcible  tracdon  in  fracture  of  the  leg. 

Suspension  may  be  employed  with  any  of  these  splints  and  promotes 
comfort  notably. 

Continuous  traction,  which  is  rarely  needed  and  available  in  simple 
fracture,  may  here  be  very  valuable  if   combined  with  suspension. 

(See  Figs.  47  and  49,  p.  98.) 

3.  FRACTURES  AT  THE  LOWER  END  OF  THE  LEG. 

In  this  group  I  place  the  rare  fractures  of  both  bones  in  which  the 
lower  end  of  the  tibia  is  crushed  or  splintered,  separation  of  the  lower 
epiphysis  of  the  tibia  and  the  allied  supramalleolar  fracture,  the  numer- 
ous and  varied  fractures  of  one  or  both  bones  at  or  near  the  joint  caused 
by  forcible  inversion  or  eversion  of  the  foot,  sometimes  aided  by  the 
weight  of  the  body,  of  which  the  most  common  is  known  as  Pott's 
fracture,  and  the  much  rarer  fractures  of  the  anterior  and  posterior 
articular  portions  of  the  tibia.  The  feature  which  almost  all  have  in 
common  is  the  action  of  the  causative  violence  through  the  foot. 
32 


448 


FRACTURES. 


Comminuted    fracture    of 
lower  portion  of  leg. 


A.  Comminuted  Fracture  of  the  Lower  End  of  the   Tibia  with  Frac- 
ture of  the  Fibula. 

The  fractures  which  constitute  this  group  are  too  rare  and  varied  to 

permit  a  systematic  description.  The  tibia  is  broken  either  by  direct 
violence  acting  upon  its  side  to  crush  it,  or,  more 
frequently  apparently,  by  a  fall  from  a  height  in 
which  the  bone  is  broken  by  a  transverse  strain 
and  then  its  lower  portion  split  by  the  penetration 
into  it  of  the  other.  Thus,  in  a  case  reported  by 
Chassaignac  the  tibia  was  broken  four  finger- 
breadths  above  the  joint  and  the  lower  fragment 
split  into  four  pieces;  the  fibula  was  broken  at 
two  places  in  its  lower  third.  A  specimen  in  the 
museum  at  Val  de  Grace  is  shown  in  Fig.  322; 
the  lower  end  of  the  tibia  was  broken  into  frag- 
ments. 

Diagnosis.  The  diagnosis  must  be  made  by 
recognition  of  the  abnormal  mobility  and  the 
mobility  of  the  fragments;  probably  the  aid  of 
anaesthesia  or  the  .r-rays  would  always  be  necessary 
to  appreciation  of  the  details. 

Treatment.  The  treatment  must  aim  to  effect 
and  maintain  as  complete  reduction  as  possible, 
acting  upon  the  fragments  by  traction  through  the 

foot  and  by  direct  pressure.    The  im- 
plication of  the  joint  and  the  frequent 

derangement  of  the  articular  surface  by 

fragmentation  make  loss  of  function  in 

the  ankle-joint   inevitable,  and  there- 
fore   the  foot  must  be  maintained  at 

right  angles  to   the  leg  and  without 

eversion  or  inversion   of   the    sole  in 

order  that  its   usefulness  may  not  be 

further  diminished  by  a  fixed  faulty 

position.    If  the  injury  is  compound 

by  direct  violence,  amputation  may  be 

expected  to  give   a  better  functional 

result  than  conservative  treatment  in 

most  cases. 

B.  Supramalleolar  Fracture. 

This  term  was  created  by  Malgaigne 
and  applied  to  fractures  which  for  the 
most  part  were  low  or  partial  forms  of 
the  preceding  class,  the  line  of  fracture 
always    running    into    the   joint    and 

usually    comminuting    the     end     of     the  supramalleolar  fracture 


FRACTURES  OF   THE  BONES  OF   THE  LEG. 


449 


bone,  but  there  are  cases  in  which  the  tibia  is  broken  across 
within  an  inch  or  two  of  its  lower  surface  and  with  fracture  of  the 
fibula  at  or  above  the  same  level.  I  have  seen  one  in  which  the 
tibia  was  broken  squarely  across,  one  inch  above  its  lower  end, 
the  fibula  was  broken  at  the  junction  of  the  upper  and  middle  thirds, 
and  the  tip  of  the  external  malleolus  was  broken  oft'.  Tillaux^  was  able 
to  produce  this  form  experimentally  by  inversion  of  the  foot,  and  says 
the  fracture  then  takes  place  first  in  the  fibula,  and  only  in  the  tibia  if 
the  force  continvies  to  act;  he  reports  one  case  in  which  dislocation  of 
the  upper  end  of  the  fibula  took  the  place  of  fracture  of  that  bone,  the 
line  of  fracture  of  the  tibia  lying  three  finger-breadths  abo^'e  its  lower 
surface.  In  the  few  cases  I  have  seen  the  mechanism  could  not  be 
learned,  but  I  see  no  reason  to  doubt  that  it  can  be  effected  also  by 

Fig.  324. 


Supramalleolar  fracture. 

aversion  of  the  foot;  in  the  case  above  quoted  the  lower  fragment  could 
be  easily  displaced  outward,  but  not  inward. 

Diagnosis.  The  diagnosis  is  made  by  pain  on  pressure  along  the  line 
of  fracture  and  on  pressing  the  foot  up  against  the  leg,  and  ])()ssibl\  by 
recognition  of  abnormal  mobility  and  cre])itus. 

Treatment.  The  treatment  is  immobilization,  i^referably  in  a  fixed 
dressing,  using  the  foot  to  control  the  position  of  the  lower  fragment. 


C.  Separation  of  the  Epiphysis  of  the  Tibia. 

This  is  more  frequent  than  that  of  the  u])])rv  cpiplix  sis,   11   to   1  in 
Bruns's  100  cases  of  all  kinds.     The  common  ciuise  appears  to  be  a 


1  TilUiux:  Analimiie  topofinipliiiiiK 


1174. 


450 


FRACTURES. 


Fig.  325. 


cross-strain  in  eversion  and  perhaps  in  inversion  of  the  foot,  sometimes 
the  result  of  great  violence,  as  in  a  fall  from  a  height,  sometimes  a 
simple  twisting  of  the  foot  in  a  inisstep.  In  some  cases,  as  in  Fig.  325,, 
the  outer  portion  of  the  shaft  is  broken  off,, 
evidently  during  eversion;  and  in  some  the 
injury  is  compound  with  marked  protrusion 
of  the  shaft  through  the  wound  on  the  inner 
side.  The  fibula  is  almost  always  broken  at  a 
higher  point,  and  although  the  upper  limit 
of  its  own  epiphysis  is  situated  well  below 
that  of  the  tibia  its  separation  occasionally 
takes  the  place  of  fracture  of  the  shaft. 

Two  variants  are  sometimes  seen,  the  result 

apparently  of  production  bj^  hyperflexion  or 

extension  respectively;  the  separation  follows 

the  line  of  the  conjugal  cartilage  for  only  a 

portion  of  its  antero-posterior  length  and  then 

diverges  to  break  off  a  fragment  from  the  shaft 

either  in  front  or  behind.    (See  Bruns's  Beitrdge 

zur  klin.  Chir.,  vol.  77.) 

Hutchinson  collected  eight  reported  cases  of  arrest  of  growth  after 

the  injury,  with  overgrowth  of  the  fibula  and  inversion  of  the  foot. 

The  principle  of  treatment  is  the  same  as  in  supramalleolar  fracture. 


Separation  of  the  lower  epiph- 
ysis of  the  tibia.    (Brunj.) 


D.  Fractures  by  Eversion  and  Abduction  of  the  Foot.     Pott's  Fracture. 

Besides  being  a  verj  common  injury  this  gains  special  importance 
from  the  frequency  with  which  the  cardinal  principles  of  its  treatment 
are  overlooked  and  the  occasional  great  disability  which  results.  The 
lesions  vary  much  in  extent  and  detail;  indeed,  occasionally  fracture 
is  wholly  absent  and  some  of  the  forms  have  been  classed  with  disloca- 
tions. But  these  differences  are  due  either  to  alternative  lesions  or 
to  the  early  cessation  of  the  force  before  the  typical  form  has  been 
reached,  and  the  mode  of  production  in  its  two  forms  is  constant,  so 
that  all  the  variations  are  parts  of  a  single  nosological  entity.  The 
differences  make  a  name  anatomically  descriptive  of  the  group  almost 
impossible;  the  one  above  given,  based  on  the  mode  of  production,  is 
useful  to  distinguish  the  group  from  the  following  one  which  has  cer- 
tain points  of  resemblance,  and  correctly  includes  all  the  forms,  but  it 
is  not  suitable  for  current  use;  the  alternative  title,  Pott's  fracture, 
has  not  only  the  advantage  of  convenience  but  also  that  of  long  asso- 
ciation with  the  injury.  It  deserves,  I  think,  to  be  retained  as  the 
principal  name. 

Cause  and  Pathology.  The  cause  is  a  twist  of  the  foot — eversion 
and  abduction — aided  somewhat  by  the  weight  of  the  body.  Accord- 
ing as  the  eversion  or  the  abduction  predominates  the  lesions  take  one 
or  the  other  of  two  easily  distinguishable  forms,  as  follows  ;t- 

If  eversion  is  the  sole,  or  main,  movement  the  force  is  exerted. 


FRACTURES  OF   THE  BONES  OF   THE  LEG. 


451 


through  the  internal  lateral  ligament  and  breaks  the  internal  malleolus 
squarely  off  at  its  base;  then  it  presses  the  external  malleolus  out- 
ward, rupturing  the  tibio-fibular  ligament,  and  breaks  the  fibula  close 


Fig.  326. 


Pott's  franture  by  abduction;   a; -ray  tracing. 

Fig.  327. 


Pott's  fracture  by  evcrsion;   x-ray  tracing. 


452 


FRACTURES. 
Fig.  328. 


Pott's  fracture,  right  side;  showing  outward  displacement  and  absence  of  eversion. 

Fig.  329. 


The  same;  showing  backward  displacement. 


FRACTURES  OF   THE  BONES  OF   THE  LEG. 
Fig.  330. 


453 


Separation  of  lower  tibial  epiphysis. 
Fig.  331. 


Fotfb  fraclure  by  eversiun  in  a  yuuth  ;  sliowing  also  cpiphyseai  line;  internal  malleolus  broken 

at  its  base. 


454 


FRACTURES. 
Fig.  332. 


Fracture  of  the  posterior  portion  of  the  lower  end  of  the  tibia,  with  fracture  of  fibula  and 

internal  malleolus. 

Fig.  333. 


Putt's  fracture  by  abduction;  male,  forty  years;  internal  malleolus  unbroken. 


FRACTURES  OF   THE  BONES  OF   THE  LEG. 
Fig.  334. 


455 


Pott's  fracture,  two  months  old,  backward  displacement. 


Fig.  335. 


Pott's  fracture  by  abduction  ;  saiue  as  Fig.  ,331. 


456 


FRACTURES. 
Fig.  336. 


Bimalleolar  fracture  by  inversion ;  boy  foiirteen  years.    External  malleolus  separated  at  epi- 
physeal line  ;  fracture  of  internal  malleolus  does  not  show,  but  was  recognized  clinically. 

Fig.  337. 


Pott's  fracture  wjth  wide  displacement. 


PLATE  XXVI 


Fracture  by  Evorsion  NA'ith  Interposition  of  Astragalus. 


FRACTURES  OF   THE  BONES  OF   THE  LEG.  457 

above  the  malleolus.  Sometimes,  instead  of  pure  rupture  of  the  tibio- 
fibular ligament,  there  is  avulsion  of  the  portion  of  the  tibia  to  which 
it  is  attached,  in  front  or  behind  or  both,  but  I  believe  this  to  be  rare. 
These  lesions  can  be  easily  produced  experimentally  by  fixing  the  foot 
in  a  vise  and  pressing  the  upper  part  of  the  leg  outward. 

If,  on  the  other  hand,  abduction  of  the  front  of  the  foot  is  the 
principal  movement  the  first  and  last  of  these  three  lesions  vary: 
instead  of  a  square  break  of  the  internal  malleolus  at  its  base,  there 
is  an  oblique,  almost  marginal,  fracture  of  its  anterior  portion,  or, 
more  commonly,  there  is  ruptm-e  of  the  anterior  portion  of  the  internal 
lateral  ligament;  then  follows  rupture  of  the  tibio-fibular  ligament, 
and,  as  the  movement  continues,  the  torsion  of  the  fibula  produces  an 
oblique  fracture,  the  upper  end  of  which  is  found  three  or  four  inches 
above  the  tip  of  the  malleolus.  If  the  movement  is  arrested  in  time 
fracture  of  the  fibula  may  not  occur.  Experimentally,  this  can  be  easily 
produced  and  the  sequence  of  events  accurately  observed.  Clinically 
it  cannot  be  demonstrated  so  easily,  for  the  patient  can  rarely  give  a 
detailed  account  of  the  manner  in  which  the  injury  was  received,  but 
in  one  of  my  cases  the  mechanism  was  evident:  while  the  patient  was 
kneeling  on  one  knee,  the  foot  resting  on  the  hyperextended  toes,  he 
was  pressed  backward  so  that  his  buttocks  rested  on  and  forced  the 
ankle  inward,  causing  abduction  of  the  front  of  the  foot.  The  essen- 
tial lesion  is  the  tibio-fibular  diastasis,  the  rupture  of  those  ligaments, 
and  the  consequent  widening  of  the  mortise  within  which  the  astrag- 
alus is  held. 

Exceptionally  the  displacement  of  the  foot  and  fibula  may  be 
extreme,  even  without  fracture  of  the  fibula.  (See  Outward  Disloca- 
tion of  the  Foot.)  And,  also  exceptionally,  unusual  lines  of  fracture  of 
the  tibia  may  be  found,  such  as  a  long  one  running  up  from  the  articular 
surface  and  separating  a  fragment  consisting  of  the  outer  portion  of 
the  bone,  or  a  breaking  off  of  the  posterior  portion  of  the  articular 
surface^  (see  section  F) ;  in  both  of  these  the  weight  of  the  body  must 
be  an  important  causative  factor. 

Two  complications  which  may  appear  in  the  first  variety  were,  so 
far  as  I  know,  first  observed  and  reported  by  me;^  I  have  seen  two 
cases  of  each.  One  is  the  rotation  of  the  internal  malleolus  about  an 
aiitero-posterior  axis  so  that  its  fractured  surface  lies  parallel  to  and 
just  beneath  the  skin,  the  fragment  being  exceptionally  prominent  and 
movable.  The  other  is  the  interposition  between  the  malleolus  and  the 
tibia  of  a  large  strip  of  periosteum  torn  from  the  tibia;  in  this  condi- 
tion also  the  malleolus  is  exceptionally  prominent  and  movable.  In 
all  my  four  cases  the  fracture  was  exposed  and  readjustment  made 
through  an  incision;  recovery  followed  with  full  restoration  of  function. 

A  third  case  of  the  first  form  recently  (1909)  seen  is  interesting  as 

1  Cotton  (Journ.  Am.  Med.  Ass.,  1915,  p.  .318)  thinks  this  is  almost  always  present 
where  there  is  backward  disloeation.     I  have  not  so  found  it. 

2  Stimson:  Transactions  of  the  New  York  Surgical  Society,  in  Xcw  York  Medical  .Jour- 
nal, .January  26,  1889,  p.  108,  and  Pott's  Fracture,  New  York  Medical  Journal,  .June  2.5, 
1892. 


458 


FRACTURES. 


a  variant  and  as  showing  one  form  of  mechanism  clearly.  A  man 
caught  between  an  elevator  and  its  shaft  receiving  an  injury  at  the  ankle 
and  also  a  low  compound  fracture  of  the  thigh  with  laceration  of  the 
popliteal  vessels  which  made  amputation  necessary.  The  internal  mal- 
leolus was  broken  off  at  its  base  and  so  rotated  that  its  fractured  sur- 
face faced  the  skin.      It  was  held  in  position  by  slight  interposition  of 


Fig.  338. 


Fig.  339. 


Pott's  fracture;  method  of  recognizing  abnormal  lateral  mobility. 

the  tendon  of  the  tibialis  posticus,  but  could  be  easily  replaced,  and  as 
easily  redislocated  by  eversion  of  the  sole.  The  external  malleolus  and 
the  lower  tibio-fibular  ligaments  were  uninjured.  On  exposing  the 
joint  in  front  and  gently  everting  the  sole  the  astragalus  could  be  seen  to 
turn  slightly  on  the  external  malleolus  as  a  centre  and  press  with  its 
upper,  inner  border  the  internal  malleolus  out  of  place.  The  fracture 
appeared  to  have  been  caused  by  the  pressure  of  the  astragalus,  not  by 
avulsion  through  the  deltoid  ligament.  The  case  differs  from  the  com- 
mon form  in  the  absence  of  the  associated  pressure  downward  which 
must  habitually  co-exist  when  the  injury  occurs  while  the  patient  is 
standing. 


FRACTURES  OF   THE  BONES  OF   THE  LEG. 


459 


Another,  not  very  uncommon,  complication  of  the  first  variety  is 
laceration  of  the  skin  on  the  inner  side  by  the  end  of  the  tibia,  which 
may  project  through  the  wound;  this  is  due  to  the  prolongation  of  the 
action  after  fracture,  by  which  the  foot  is  forced  outward  and  everted 
and  the  skin  torn  across  the  broken  edge  of  the  tibia.  The  displace- 
ment is  of  the  foot  (astragalus)  and  outer  malleolus  outward  and  back- 
ward. This  displacement  is  usually  slight,  a  quarter  of  an  inch,  but 
it  may  be  much  more,  and  the  backward  displacement  is  sometimes  so 


Fig.  340. 


Fig.  341. 


# 


Old  Pott's  fracture;  outward 
displacement. 


The  same;  backward  displacement. 


great  that  the  body  of  the  astragalus  lies  almost  wholy  behind  the  tibia. 
In  an  old  case  of  this  kind  1  found,  on  operation,  and  r(Mn()\c(l,  a.  hirge 
bony  spur  of  new  formation  growing  from  the  back  of  the  tibia,  just 
above  its  uninjured  articular  border.  I  ])resume  it  was  formed  1)\-  the 
detached  periosteum,  like  the  spur  (•a])i)ing  the  head  of  the  radius  in 
an  old  unreduced  backward  dislocation  of  the  elbow. 


460  FRACTURES. 

Symptoms.  The  appearance  of  the  region  is  usually  so  characteristic 
that  the  diagnosis  can  be  made  at  a  glance,  the  characteristic  feature 
being  the  outward  displacement  of  the  foot  and  the  corresponding  prom- 
inence of  the  internal  malleolus  or  the  adjoining  portion  of  the  tibia 
(Fig.  328);  in  the  marked  cases  the  backward  displacement  is  also 
plainly  to  be  seen  (Fig.  329).  The  former  is  most  apparent  when  the 
muscles  are  relaxed,  as  by  anaesthesia,  or  when  swelling  is  absent. 

The  pathognomonic  signs  are  the  points  of  tenderness  m.entioned 
below  and  abnormal  lateral  mobility  at  the  ankle,  which  can  be  shown 
by  grasping  the  foot  'mth  one  hand  so  that  the  posterior  portion  of  the 
sole  rests  in  the  palm,  with  the  thumb  close  below  the  external  malle- 
olus, and  the  index-finger  below  the  internal  malicious,  and  moving  it 
bodily  inward  and  outward  while  the  other  hand  grasps  the  leg  above 
the  ankle  and  steadies  it  (Figs.  338  and  339).  This  manipulation  some- 
times produces  a  distinct  click  by  the  impact  of  the  astragalus  against 
the  internal  malleolus  or  of  the  external  malleolus  against  the  tibia. 

In  like  manner  abnormal  mobility  backward  and  forward  can  some- 
times be  shown  by  clasping  the  back  of  the  heel  with  the  fingers  of 
both  hands,  placing  the  thumbs  on  the  front  of  the  lower  part  of  the 
tibia,  and  then  alternately  lifting  the  foot  and  allowing  it  to  drop  back, 
the  patient  being  recumbent. 

Three  points  of  tenderness  on  pressure  are  constant  and  character- 
istic: one  in  front  at  the  position  of  the  tibio-fibular  ligament,  that  is, 
in  the  groove  between  the  tibia  and  the  external  malleolus,  showing 
the  rupture  of  this  ligament;  one  at  the  base  of  the  internal  malleolus 
or  near  its  anterior  border  or  just  in  front  of  it,  marking  the  fracture 
of  the  malleolus  or  the  rupture  of  the  anterior  portion  of  the  lateral 
ligament;  the  third  over  the  outer  aspect  of  the  fibula,  close  above  the 
malleolus  in  the  first  variety,  an  inch  or  so  higher  in  the  second,  mark- 
ing the  fracture  of  the  fibula.  Abnormal  mobility  of  the  two  frag- 
ments may  sometimes  be  recognizable. 

Marked  ecchymosis  appears  beneath  the  external  malleolus  and 
usually  also  beneath  the  internal. 

Pressure  upward  against  the  heel  is  not  painful,  and  the  patient  can 
sometimes  walk  if  he  steps  carefully  and  without  much  movement  in 
the  ankle-joint. 

Prognosis.  If  reduction  is  made  and  maintained  the  prognosis  is 
good,  the  patient  almost  always  gaining  full  use  of  the  joint,  but  if 
either  backward  or  outward  displacement  persists  (Figs.  340  and  341) 
the  disability  is  likely  to  be  marked.  Backward  displacement  limits 
dorsal  flexion  at  the  ankle,  and  the  patient  is,  therefore,  obliged  to  turn 
the  toes  well  outward  in  walking;  outward  displacement  brings  the 
weight  of  the  body  too  far  to  the  inner  side  of  the  foot  and  thus  pro- 
duces a  strain  upon  the  internal  lateral  ligament  which  promptly  causes 
fatigue  and  pain. 

Treatment.  Reduction,  to  facilitate  which  anaesthesia  is  sometimes 
advisable,  is  made  by  pressing  the  calcaneum  forward  and  inward;  the 
hand  is  placed  against  the  back  and  outer  side  of  the  heel  and  pressed 
forward  and  then  forcibly  inward.     It  is  best  maintained  by  a  poste- 


FRACTURES  OF   THE  BONES  OF   THE  LEG. 


461 


rior  and  a  lateral  plaster  splint,  such  as  those  shown  in  Figs.  o42  and 
343.  They  are  preferable  to  complete  encasement  in  plaster  because 
they  permit  inspection  of  the  inner  side  of  the  ankle  and  the  immediate 
detection  of  recurrence,  and  to  wooden  splints  (Fig.  344)  because  they 
are  more  secure.    They  can  be  conveniently  made  of  a  four-inch  plaster 

Fig.  342. 


Pott's  fracture;  posterior  plaster  splint. 

Fig.  343. 


Pott's  fracture;   lateral  plaster  splint. 


roller  by  soaking  it  and  running  it  back  and  forth  on  a  table  until 
twelve  or  fifteen  layers  of  suitable  length  have  been  put  together.  The 
posterior  splint  should  extend  from  the  toes,  along  the  sole,  and  up  the 
calf  nearly  to  the  knee.    The  lateral  one  should  begin  just  in  front  of 


Fig.  344. 


Dupuytren's  splint. 


one  malleolus,  pass  over  the  dorsum  of  the  foot  to  the  other  side, 
under  the  sole,  and  up  along  the  side  of  the  leg  to  the  same  height. 
They  are  snugly  molded  and  bound  to  the  limb  while  still  ^^•et  with  a 
roller-bandage,  which  may  be  rem()\'ed  after  the  plaster  has  set  its, 


462 


FRACTURES. 


place  being  taken  by  a  few  turns  of  a  bandage  just  above  the  ankle 
and  at  the  upper  end  of  the  splint.  While  the  plaster  is  setting  reduction 
must  be  maintained  by  an  assistant,  or  by  resting  the  heel  on  a  sand- 
bag with  the  limb  in  outward  rotation,  so  that  the  foot  will  be  pressed 
forward  and  inward. 


Fig.  345. 


Fig.  346. 


Pott's  fracture;  same  case  as  in  Figs.  340  and  341;  showing  result  of  operation. 

Such  a  splint  may  be  conveniently  and  safely  applied  immediately 
after  the  accident,  for  if  strangulation  should  threaten  the  circular 
bandages  can  be  loosened  sufficiently  to  relieve  the  constriction  without 
disturbing  the  position  of  the  foot.  If  applied  while  the  limb  is  swol- 
len the  shrinking  can  be  met  by  tightening  the  circular  bands,  but  it 
is  better  to  apply  a  new  one  after  a  few  days. 

In  compound  fracture  with  a  small  wound  infection  can  generally  be 
avoided  by  the  usual  measures,  and  a  good  result  obtained.  If  the 
wound  is  or  should  become  infected  drainage  must  be  made  on  both 
sides,  and  the  foot  kept  square  upon  the  leg  that  its  usefulness  may  be 
as  great  as  possible  after  the  probable  result  of  anchylosis. 


FRACTURES  OF   THE  BONES  OF   THE  LEG.  463 

In  the  rare  cases  of  rotcdion  of  the  internal  mallcohis  or  hiterpusition 
of  a  strip  of  periosteum  the  condition  should  he  corrected  through  an 
open  incision. 

In  old  fractures  with  unreduced  displacement  relief  can  he  had  onlv  hy 
operation.  Supramalleolar  osteotomy  enahles  the  foot  to  l)e  hroiight 
hack  into  line  with  the  leg,  hut  does  not  correct  the  hackward  dis])lace- 
ment  which  almost  always  coexists.  I  have  never  employed  it,  hut 
have  always  resorted  to  a  formal  attempt  to  hring  the  astragalus  and 
external  malleolus  hack  to  their  places,  using  two  lateral  incisions,  as 
follows  (Figs.  345,  346) : 

One  incision  hegins  at  the  front  of  the  tibula  three  inches  ahove  the 
ankle,  is  carried  downward,  passing  in  front  of  the  malleolus,  and  then 
curved  forward  on  the  side  of  the  foot;  the  fracture  is  exposed  and  the 
lower  fragment  again  detached.  The  second  incision  begins  on  the 
inner  side  of  the  tibia  at  the  same  level  as  the  first  and  passes  down  to 
the  front  of  the  malleolus  and  thenceforward  to  or  beyond  the  tubercle 
of  the  scaphoid.  Through  it  the  internal  malleolus,  if  it  was  broken 
off  in  the  original  injury,  is  again  detached  from  the  tibia  with  a  chisel, 
and  the  end  of  the  tibia  protruded  so  that  it  is  easy  to  lil)erate  the 
astragalus  and  cut  away  any  new  growth  of  bone  that  may  have  formed 
on  the  back  of  the  tibia  or  a  fragment  of  its  posterior  lip.  The  foot 
is  then  easily  restored  to  place,  the  incisions  closed,  and  a  bulky  dressing 
applied  and  covered  with  plaster  of  Paris.  In  the  nine  or  ten  cases 
in  which  I  have  done  this  the  restoration  of  form  has  been  complete, 
and  that  of  function  always  an  improvement  upon  the  previous  con- 
dition and  sometimes  a  very  marked  one. 

E.  Fractures  of  the  Malleoli  by  Inversion  of  the  Foot. 

This  injury,  which  also  is  a  common  one,  presents  several  varieties 
dif^'ering  notably  in  the  extent  of  the  lesions,  the  immediate  disability, 
and  the  prognosis.  The  fibula  may  be  alone  broken  at  or  close  above 
the  base  of  the  malleolus  or  at  the  epiphyseal  line  in  the  young,  or 
with  its  fracture  may  be  associated  that  of  the  tip  of  the  internal  mal- 
leolus or  one  passing  obliquely  upward  and  inward  through  the  tibia 
and  separating  a  fragment  composed  of  the  internal  malleolus  and  a 
considerable  portion  of  the  adjoining  bone  (Figs.  336  and  348).  The 
variations  appear  to  be  due  to  differences  in  the  amount  or  force  of 
the  inversion  and  to  the  extent  to  which  the  weight  of  the  body  acts 
as  a  factor.  Thus,  the  first  effect  of  inversion  is  to  break  the  fibula, 
either  by  the  pressure  of  the  upper  edge  of  the  astragalus  against  it  or 
by  the  pull  of  the  external  lateral  ligament;  if  the  movement  is  con- 
tinued, or  possibly  if  its  direction  is  somewhat  different,  the  astragalus 
presses  against  and  breaks  off  the  tip  of  the  internal  malleolus  (See 
case  on  page  458) ;  but  if  the  weight  of  the  body  is  added,  as  in  a  fall 
upon  the  inverted  foot,  the  astragalus  presses  upward  and  inward 
against  the  inner  portion  of  the  tibia  and  breaks  oft'  the  larger  fragment. 

The  first  form  of  the  injury,  fracture  of  the  ext(M-nal  malleolus  or 
fibula  alone,  is  of  slight  importance  if  the  tibio-fibular  ligament  is  not 
also  torn,  producing  no  displacement  of  the  astragalus  and  getting  well 


464 


FRACTURES. 
Fig.  347. 


Fracture  of  both  malleoli  by  inversion. 

Fig.  348. 


Bimalleolar  fracture  by  inversion  in  a  youth.     Line  of  fracture  passing  above  the  base  of  the 
internal  malleolus;  external  malleolus  separated  at  epiphyseal  line. 


FRACTURES  OF   THE  BONES  OF   THE  LEG.  465 

under  a  simple  protective  dressing.  The  same  is  nearly  equally  true 
of  the  second  form,  added  fracture  of  the  tip  of  the  internal  malleolus, 
but  more  time  is  required  before  the  limb  can  be  freely  used.  The 
third  form  is  much  more  serious  and  usually  results  in  considerable 
restriction  of  motion  at  the  joint. 

Fig.  349. 


Lung  oblique  fracture  of  tibia  and  external  malleolus. 

If  the  tibio-fibular  ligament  is  freely  torn  the  first  two  forms  are 
almost  identical  with  the  form  described  in  the  preceding  section;  there 
are  the  same  points  of  tenderness  on  the  outer  side  and  the  same  lateral 
mobility  in  the  joint. 

Diagnosis.  The  diagnosis  is  made  in  the  first  two  varieties  by  recog- 
nition of  tenderness  on  pressure  at  the  lines  of  fracture  and  of  inde- 
pendent mobility  of  the  external  malleolus  by  pressing  its  tip  inward 
while  another  finger  is  placed  at  the  seat  of  fracture  to  feel  the  tilting 
of  the  upper  end  of  the  fragment.  In  the  third  variety  the  line  of 
fracture  of  the  tibia  can  be  recognized  by  tenderness  on  pressure  and 
by  the  irregularity  produced  by  the  displacement  upward  and  inward 
of  the  fragment. 

Treatment.  For  the  first  two  varieties  it  is  sufficient  to  immobilize 
the  part  by  plaster-of-Paris  splints,  taking  care  to  keep  the  foot  well 
pressed  inward  while  the  plaster  is  setting  in  order  that  the  malleolar 
mortise  shall  not  be  widened.  In  the  third  ^'ariety  the  eft'ort  must  be 
made  to  correct  the  displacement  of  the  tibial  fragment  by  pressing  it 
downward  and  outward,  and  to  hnmobilize  with  the  foot  well  forward, 
guarding  against  backward  disiilaccment,  and  the  external  malleolus 
pressed  snugly  against  the  tibia,  guarding  against  outward  displacement. 


466  FRACTURES. 

F.  Fracture  of  the  Posterior  Portion  of  the  Articular  Surface  of  the 

Tibia.i 

This  may  be  a  complication  of  Pott's  fracture,  the  fragment  being 
rather  small,  or  the  crush  may  be  so  extensive  that  the  symptoms  and 
treatment  are  very  different.  In  the  slighter  form  the  breaking  of  the 
tibia  is  apparently  produced  by  the  weight  of  the  body  pressing  the 
posterior  and  outer  part  of  the  articular  surface  against  the  displaced 
astragalus,  and  yet  I  have  known  it  to  be  caused  by  the  comparatively 
slight  violence  of  a  fall  from  an  almost  stationary  bicycle.  In  the 
minor  cases  the  fracture  could  probably  by  recognized  only  by  the  aid 
of  the  a--rays,  and  the  treatment  is  that  of  Pott's  fracture  with  special 
care  to  bring  the  foot  .well  forward. 

The  more  severe  form  is  rare  and  apparently  the  result  of  a  fall  from 
a  height  upon  the  foot.  I  have  one  old  specimen  of  extensive  crushing 
with  fracture  of  the  external  malleolus  and  its  displacement  backward, 
but  repair  has  obliterated  most  of  the  details.  I  have  seen  another 
in  the  collection  of  Dr.  Dandridge,  of  Cincinnati,  in  which  the  pos- 
terior half  of  the  tibial  plateau  is  broken  off  and  has  united  with  the 
back  of  the  tibia  after  displacement  of  more  than  half  an  inch  upward. 
The  fibular  fragment  is  rather  short  and  is  displaced  angularly,  the 
astragalus  having  slipped  outward  between  it  and  the  tibia;  the 
internal  malleolus  is  broken  off  at  its  base  and  has  accompanied  the 
astragalus.  In  two  old  cases  treated  by  operation  (Figs.  350  and  351) 
I  have  found  similar  lesions  and  displacements. 

Probably  under  an  anaesthetic  the  general  condition,  if  not  the 
details,  could  be  recognized  by  palpation.  The  treatment  would  be 
to  make  such  reduction  as  was  possible  and  to  immobilize  in  plaster 
splints. 

Cotton  (loc.  cit)  recommends  that  the  foot  should  be  kept  in  full 
dorsal  flexion. 

In  two  cases  I  have  removed  the  posterior  fragment  of  the  tibia, 
corrected  the  displacement,  and  obtained  a  useful  limb  with  obliteration 
of  the  ankle-joint.  In  a  third,  I  removed  the  remaining  articular  sur- 
face of  the  tibia  and  flattened  the  top  of  the  astragalus  so  that  the  two 
became  firmly  united;  the  functional  result  was  excellent. 


G.  Fracture  of  the  Anterior  Portion  of  the  Articular  Surface  of  the 

Tibia. 

Only  one  or  two  cases  of  this  variety  have  been  reported.  It  is 
evidently  produced  by  the  pressure  of  the  astragalus  against  the  anterior 
lip  of  the  tibia.  Displacement  could  probably  be  corrected  by  traction 
through  the  anterior  portion  of  the  capsule  in  forced  depression  of  the 
front  of  the  foot  aided  by  direct  pressure  upon  the  fragment. 

1  See  also  Backward  Dislocation  of  the  Foot. 


I 


PLATE  XXVII 


Longitudinal  Fracture  of  Lower  End  of  the  Tibia  by  a  Fall  upon 
and  Inversion  of  the  Foot. 


FRACTURES  OF  THE  BONES  OF  THE  LEG.  467 

Fig.  350. 


Fracture  and  displacement  of  the  posterior  portion  of  the  lower  articular  surface  of  the  tibia 
and  of  the  fibula  and  internal  malleolus.    (See  also  Fig.  332.) 

Fig.  351. 


Same  case  as  Figure  3.50. 


468 


FRACTURES. 


4.  FRACTURES  OF  THE  FIBULA. 


A.   Fracture  of  the  Upper  End.^ 

This  may  be  caused  by  direct  violence,  by  muscular  action  (contrac- 
tion of  the  biceps),  or  more  commonly  by  forcible  adduction  of  the  leg 
acting  through  the  external  lateral  ligament  attached  to  the  head  of 
the  fibula.  In  two  of  the  reported  cases  (Stirason,  Weir)  the  lesion 
was  a  separation  of  the  epiphysis.  In  a  number  of  the  cases  paralysis 
of  the  extensor  and  peroneal  muscles  and  loss  of  sensation  in  the  region 
supplied  by  the  musculo-cutaneous  branch  of  the  peroneal  nerve  were 
noticed  shortly  after  the  accident,  and  in  some  ])ersisted  until  the 
patients  passed  from  observation.  Weir  and  Marchant  exposed  the 
nerve  in  their  cases  and  found  it  unbroken  but  apparently  compressed 
by  the  edge  of  the  fragment;  the  patients  recovered  almost  completely 
from  the  paralysis. 

The  upper  fragment  has  been  widely  displaced  upward  in  most  of 
the  cases,  and  it  has  usually  been  impossible  to  bring  it  fully  back  to 
its  place,  but  it  does  not  appear  that  any  disability  has  resulted  there- 
from. 

Fig.  352. 


Fracture  by  avulsion  of  a  scale  from  head  of  fibula.     Biceps  relaxed;  anterior  lateral  ligament 
torn  and  consequent  lateral  motion  in  .joint. 

Fig.  352  shows  a  unique  case  of  avulsion  of  a  scale  from  the  upper 
part  of  the  head  shown  me  by  Dr.  Ray  at  Belle vue  Hospital  in  1913. 

1  For  reported  cases,  which  are  not  numerous,  see  the  first  edition  of  this  work  and 
Gurlt's  Knochenbriiche,  vol.  i,  p.  243;  Duplay,  Bull,  de  la  Soc.  de  Chirurgie,  1880,  p.  218; 
Terrier  Idem  p.  222;  Leggatt,  Lancet,  March  31,  1888;  Hirschberg,  Arch,  fiir  khn.  C  hir., 
vol  xx'xvii  p.  199;  Weir,  New  York  Medical  Journal,  May  26,  1888;  Marchant,  La 
France  Med.,  February  21,  1889;  and  Chapin,  New  York  Medical  Journal,  September, 
1891,  p.  12. 


FRACTURES  OF   THE  BONES  OF   THE  LEG.  469 

The  patient  had  been  caught  in  a  fly-wheel  and  whirled  about.    The 
external  lateral  ligament  of  the  knee  was  also  torn. 

Treatment.  The  treatment  consists  in  approximation  of  the  frag- 
ments by  bandaging  aided  by  flexion  of  the  knee  to  relax  the  biceps  and 
plaster  of  Paris  to  prevent  adduction  of  the  leg.  If  peroneal  paralysis 
exists  it  would  probably  be  well  to  expose  the  nerve  for  some  little 
distance  above  and  below  the  fracture  in  order  to  reunite  it  if  it  is  torn 
or  to  relieve  pressure  upon  it. 

B.  Fractures  of  the  Shaft. 

These  fractures  are  generally  produced  by  direct  violence,  but  Hop- 
pengiirtuer  ^  reports  eighteen  cases  in  young  soldiers  caused  by  a  fall 
with  a  twist  of  the  foot  or  in  running ;  in  all  the  fracture  was  four 
fingerbreadths  above  the  malleolus.  The  displacement  is  slight  because 
of  the  support  given  by  the  tibia,  and  the  diagnosis  is  made  upon  the 
localized  pain  and  possibly  crepitus  and  recognizable  mobility  or  irregu- 
larity of  outline.  Occasionally  symptoms  indicative  of  iujurv  to  the 
cutaneous  branch  of  the  peroneal  nerve  are  present,  presumably  by  the 
violence  which  caused  the  fracture. 

Treatment.  The  only  treatment  needed  is  protection  against  external 
violence  and  movement  of  the  lower  fragment  by  twisting  the  foot; 
this  is  conveniently  given  by  a  plaster  or  silicate  dressing  extendino- 
from  the  toes  to  the  knee.  It  should  be  worn  for  about  three  weeks, 
and  care  should  be  taken  for  a  fortnight  longer  to  avoid  muscular  strain 
and  lateral  pressure  by  the  foot  at  the  ankle. 

C.   Separation  of  the  Lower  Epiphysis. 

Poland^  has  collected  four  cases  of  this  injury  uncomplicated  by 
fracture  of  the  tibia.  In  three  the  injury  was  compound.  One  patient 
(Allis)  died  of  tetanus,  in  one  (Wright)  the  lower  fragment  became 
necrosed,  and  in  the  third  (Poland)  gangrene  occurred  on  the  third  day 
after  the  application  of  a  plaster  dressing.  In  two  other  cases  (speci- 
mens in  the  Middlesex  and  London  Hospitals)  three  were  extensive 
associated  injuries  amounting  to  dislocation  of  the  ankle  and  requiring 
amputation.     (See  also  Fig.  336.) 

1  Hopjiensartner :  Zentralblatt  fiir  C'hir.,  1907,  p.  1157. 

2  Poland  :   Loc.  cit.,  p.  860. 


CHAPTEE  XXVI. 


FRACTURES  OF  THE  BONES  OF  THE  FOOT. 


1.  FRACTURES  OF  THE  ASTRAGALUS. 

These  are  commonly  the  result  of  falls  from  a  height,  the  bone 
being  broken  between  the  calcaneum  and  the  tibia,  and  the  lesion  being 
frequently  associated  with  fracture  of  the  calcaneum  and  with  disloca- 
tion at  the  ankle  and  fracture  of  the  fibula ;  in  other  cases  the  force 
acts  transversely. 

The  direction  and  extent  of  the  line  of  fracture  vary  greatly ;  the 
bone  may  be  divided  transversely,  or  longitudinally,  or  horizontally, 
or  obliquely,  or  into  several  pieces,  and  the  fragments  may  be  widely 
separated  and  dislocated. 

Fig.  353.' 


M 

■ 

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K  ^IP^IjH 

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k    »         .J^^^M 

l^^m  ^'^KUik^  \^^ 

ll 

^>^^H 

^^^ 

IH 

Fracture  of  the  astragalus  through  the  lower  articular  surface. 

When  there  is  no  displacement  or  external  wound  the  diagnosis  may 
be  very  difficult,  because  the  symptoms  are  not  distinctive  and  indicate 
only  severe  injury  to  the  foot,  pain,  swelling,  inability  to  bear  the  weight 
of  the  body  on  it,  and  perhaps  crepitus  on  handling  or  flexing  and 
extending  it.  The  diagnosis  must  be  made  by  exclusion  of  other 
injuries,  by  localized  pain,  and  possibly  by  recognition  of  a  displaced 
fragment,  or  of  independent  mobility  of  the  head  of  the  bone.  I  have 
once  found  it  by  the  a-rays,  in  combination  with  fracture  of  the  os 
calcis  and  witliout  displacement,  when  unable  to  recognize  it  clinically. 

When  there  is  no  displacement  treatment  is  directed  simply  to  inniio- 
bilize  the  joint  and  control  the  inflammation  ;  a  plaster  bandage  should 
(470) 


PLATE  XXVIII 


Fracture  of  Inner  Portion  of  the  Body  of  the  Astragalus. 


FRACTURES   OF  THE  BONES   OF  THE  FOOT.  471 

be  applied,  especial  attention  being  given  to  the  position  of  the  foot, 
which  should  be  at  right  angles  to  the  leg  in  the  antero-posterior  plane 
and  without  inversion  or  eversion. 

If  a  fragment  is  broken  from  the  upper  articular  surfoce  of  the  body 
it  should  be  removed.  If  the  neck  has  been  broken  and  the  head  dis'- 
placed  it  should  be  restored  to  its  place,  by  an  incision  if  necessary,  or 
removed  if  it  is  found  to  be  completely  detached.  If,  in  addition, 'the 
body  has  been  rotated  in  its  socket  it  must  be  readjusted,  or,  that  failing, 
removed.  If  the  body  should  prove  to  be  crushed  or  comminuted  its 
total  excision,  with  or  without  the  head  and  neck,  will  probably  yield 
a  much  better  functional  result  than  conservative  treatment. 

In  compound  fractures  by  direct  violence  removal  of  the  astragalus 
is  indicated  because  the  functional  result  is  likely  to  be  better  than  after 
even  successful  conservative  treatment.     (See  also  Dislocations.) 

Fracture  of  tlie  Processus  Posticus.^ 

This  is  the  portion  of  the  posterior  border  which  lies  between  the 
groove  for  the  tendon  of  the  flexor  longus  pollicis  and  that  for  the  ex- 
ternal lateral  ligament.  This  fracture  was  first  mentioned  by  Cloquet 
in  1844,  but  the  correct  interpretation  of  the  small  piece  of  bone  fre- 
quently found  in  this  place  has  been  asserted  by  the  anatomists  to  be  a 
developmental  vagary,  the  abnormal  persistence  of  a  small  nodule  which 
appears  in  the  second  month  between  the  tibia  and  the  astragalus. 
They  term  it  the  os  trigonum.  According  to  Lilienfeld,  the  os  tri- 
gonum  when  present  is  almost  always  found  on  both  limbs.  He 
claims  to  have  observed  12  cases  of  fracture  of  the  processus,  5  of  them 
associated  with  fracture  of  the  calcaneum.  The  diagnosis  was  made  on 
a;-ray  findings  with  local  tenderness  on  pressure  and  swelling.  Skillern 
{Aniiab  of  Svrg.,  March,  1915,  p.  372)  reports  a  case. 

2.  FRACTURE  OF  THE  CALCANEUM. 

This  bone  may  be  broken  by  a  fall  upon  the  foot  from  a  height,  by 
contraction  of  the  muscles  attached  to  the  tendo  Achillis,  by  direct 
violence,  and  by  forcible  inversion  of  the  sole  of  the  foot.  The  extent 
and  position  of  the  fracture  vary  with  the  causes. 

The  forms  of  fracture'  of  the  body  of  the  bone  may  be  grouped  as 

(1)  Separation  of  the  large  heel  piece  comprising  the  posterior  half; 

(2)  fracture  of  the  anterior  portion,  often  splintered;  (3)  a  general 
crush,  mainly  of  the  centre  or  anterior  two-thirds.  (Figs.  354-357.) 
The  cause  in  most  cases  is  a  fall  upon  the  feet. 

Symptoms.  The  symptoms  of  a  vertical  or  crushing  fracture  are 
somewhat  indefinite,  and  the  diagnosis  is  not  always  easy,  as  is  shown 
by  the  fact  that  surgeons  so  exj^erienced  as  Malgaigne,  Bonnet,  Huguier, 
and  Legouest  have  mistaken  the  injiu'v  for  fracture  of  the  fibula  or 
ankle.  The  symptoms  are  increase  of  its  transverse  diameter  (which, 
however,  may  be  completely  masked  by  the  swelling  below  and  about 

1  Lilienfeld:  Arch,  fiir  klin.  Chir.,  vol.  78,  p.  929. 

2  Sec  also  Cubot  and  Binney:  Annals  of  Surg.,  January,  1907,  p.  51. 


472  FRACTURES. 

the  malleoli),  flatness  of  the  sole  and  approxiniation  to  it  of  the  mal- 
leoli, especially  of  the  internal  one,  pain,  and  loss  of  function.  Crepi- 
tus is  either  absent  or  obscure ;  abnormal  mobility  may  be  recognized 
by  moving  the  posterior  portion  laterally.  Pain  is  caused  by  direct 
pressure  and  by  a  voluntary  effort  to  make  plantar  flexion  against 
resistance  at  the  toes.  The  tendo  Achillis  feels  less  tense  when  pressed 
upon,  and  the  depression  on  each  side  of  it  is  obliterated  by  swelling. 
The  deformity  of  the  heel  is  best  recognized  when  compared  with  its 
fellow  from  behind  while  the  patient  is  kneeling. 

Treatment.  The  treatment  is  immobilization,  preferably  with  mas- 
sage, for  about  three  weeks ;  then  passive  motion,  to  be  continued  until 
the  end  of  the  second  month,  Cabot  and  Binney  suggest  the  possible 
advisability  in  fractures  with  a  large  heel  fragment  of  over-correcting 

Ftg. 354. 


Fracture  of  os  calcis.    (Cabot.) 

the  displacement  by  drawing  the  heel  downward  and  forward.  Cotton 
and  Wilson  '  did  this  by  passing  a  stout  steel  pin  across  in  front  of 
the  insertion  of  the  tendo  Achillis  and  forcing  the  posterior  fragment 
forward  and  downward ;  they  avoid  recurrence  of  the  displacement  by 
fixing  the  foot  in  plantar  flexion  so  as  to  relax  the  muscles  of  the  calf, 
Becker^  passed  a  strong  elevator  transversely  through  the  foot  close 
beneath  the  fragments  and  forced  them  upward,  and  tlien  fixed  them 
in  place  with  a  long  nail  driven  through  them  from  the  back  of  the 
heel. 

When  the  direction  of  the  violence  with  reference  to  the  axis  of  the 
leg  is  such  that  the  foot  is  adducted  or  inverted  by  it,  the  strain  is 
brought  upon  the  external  lateral  ligament  and  the  sustentaculum  tali, 

1  Cotton  and  Wilson  :  Boston  Med.  and  Surg.  Jour.,  Oct.  29,  1908. 
»  Becker  ;  Ztlblatt.  fiir  Chir.,  1908,  p.  112. 


FRACTURES  OF  TEE  BONES  OF  THE  FOOT. 
Fig.  355. 


473 


Fracture  of  os  ealcis.    (Cabot.) 
Fig.  356. 


Fracture  of  os  ealcis. 


with  the  result  of  producing  fracture  of  the  fibula,  as  described  on  page 
464,  or  rupture  of  the  external  lateral  ligament,  or  avulsion  of  a  scale 
34 


474  FRACTURES. 

of  bone  from  the  side  of  the  calcaneum  where  the  ligament  is  inserted, 
or  fracture  of  the  sustentaculum  tali. 

With  the  first  of  these  we  have  not  here  to  deal.  A  case  of  avulsion 
of  a  scale  of  bone  came  under  my  observation  at  the  Presbyterian  Hos- 
pital in  1880 ;  the  patient  had  fallen  from  a  height  of  ten  feet,  striking 
upon  his  left  foot.  I  saw  him  on  the  following  day  and  found  the  foot 
and  ankle  much  swollen,  with  obscure  crepitus  and  pain  on  manipulation 
of  tlie  side  of  the  heel  below  the  outer  malleolus.  After  the  swelling 
had  subsided  I  could  distinctly  make  out  a  movable  flat  fragment  evi- 
dently detached  from  the  outer  side  of  the  calcaneum  below  the  mal- 

FiG.  357. 


Fracture  of  upper  posterior  portion  of  os  calcis  bj'  avulsion. 

leolus.  The  movements  of  the  foot  and  ankle  were  normal  and  paiuless 
except  when  the  peroneal  muscles  were  made  to  contract,  then  pain  was 
felt  below  the  external  malleolus.  The  sheath  of  the  tendons  of  these 
muscles  w^as  swollen  below  and  behind  the  malleolus. 

Fracture  of  the  sustentaculum  tali  was  first  described  by  Abel.^ 
In  his  first  case  the  injury  was  thought  to  be  a  Pott's  fracture  of  the 
ankle,  and  its  real  character  was  disclosed  at  the  autopsy.  The  patient 
was  a  young  man  who  in  dismounting  from  a  horse  slipped  on  a  stone 
and  turned  his  foot  forcibly  inward.     He  attempted  to  walk,  and  the 

1  Abel:  Archiv.  fiir  klin.  Chirurgie.  1878,  vol.  xxii.  p.  396. 


FRACTURES   OF  THE  BOXES   OF  THE  FOOT.  475 

position  of  the  foot  then  chang-ed  instantly  to  marked  valgus.  A  lon- 
gitudinal wound  three  inches  long  below  the  external  malleolus  opened 
the  ankle-joint  and  tlie  joint  between  the  astragalus  and  calcaneum. 
There  was  tenderness  on  pressure  below  the  internal  malleolus,  and  on 
the  fibula  above  the  external  malleolus.  These  symptoms  together 
with  the  apparent  broadening  of  the  ankle  and  eversion  of  the  foot  led 
to  the  erroneous  diagnosis  mentioned.  Erysipelas  set  in  and  the  patient 
died  on  the  fifteenth  day. 

The  fibula  and  tibia  were  found  uninjured,  the  sustentaculum  tali 
broken  off,  and  the  external  lateral  ligament  divided  in  the  line  of  tiie 
wound. 

Abel  afterward  saw  two  cases  in  which  he  thought  this  injury  had 
been  received  some  time  before.  In  both  the  foot  had  been  violently 
inverted,  and  in  one  the  sustentaculum  tali  seemed  to  be  douljled  in 
size.  The  symptoms,  primary  and  ultimate,  corresponded  to  the  fol- 
lowing, which  he  gives  as  diagnostic  of  the  injury. 

1.  The  mode  of  production  :  forcible  inversion  of  the  sole  of  the  foot. 

2.  The  immediate  change  in  the  position  of  the  foot,  from  inversion 
to  eversion,  and  the  permanent  sinking  of  the  inner  border  of  the  foot 
and  internal  malleolus  (valgus). 

3.  Shortening  of  the  heel  by  slight  displacement  of  the  calcaneum 
forward  ;  this  can  be  best  recognized  by  measuring  from  one  malleolus 
to  the  other  around  the  heel,  and  was  verified  by  experiment. 

4.  Pain  and  disabilitv. 

The  foot  should  be  immobilized  in  a  plaster  bandage  or  splints  with 
the  sole  sufficiently  inverted  to  favor  reunion  of  the  fragments,  but 
without  lengthening  of  the  external  lateral  ligaments  if  they  have  been 
torn. 

Fracture  by  muscular  action,  contraction  of  the  soleusand  gastroc- 
nemii,  has  been  observed  a  munber  of  times.  Malgaigne  collected 
eight  cases,  ratlier  briefly  reported ;  in  two  the  fracture  was  caused  by 
a  misstep,  and  in  five  by  a  fall  upon  the  feet,  in  two  of  which  it  is 
noted  that  the  patient  alighted  upon  the  ball  of  the  foot.  The  fracture 
seems  to  take  place  always  behind  the  astragalus  and  sometimes  to 
separate  only  a  portion  corresponding  to  the  insertion  of  the  tendo 
Achillis.  The  displacement  in  some  cases  was  slight,  in  others  extreme, 
four  and  one-half  inches  from  the  lower  edge  of  the  fragment  to  the 
bottom  of  the  heel  in  Constance's  ^  case,  in  which,  nevertheless,  the 
patient  made  a  good  recovery  with  perfect  use  of  the  limb,  although 
the  displacement  persisted. 

In  a  case  reported  by  Anningson "  the  meciianism  of  the  fracture 
seems  very  clear.  A  woman,  forty-two  years  old,  after  stepping  down 
from  a  doorway  to  the  sidewalk,  a  distance  of  about  six  inches,  cried 
out  that  she  had  "  put  out  her  ankle."  She  walked  home  slowly,  a 
distance  of  one  hundred  yards.  A  fragment  of  bone  was  found  two 
and  a  half  inches  above  the  heel  in  the  line  of  the  tendo  Achillis  which 
was  lacking  below  it ;  its  lower  edge  was  a  little  above  the  level  of  the 

'  Constance:  American  Journal  of  the  Mediral  Sciences,  InfcJ,  [>.  222,  quoting  from  au 
English  journal. 

'^  Auuiugson  :  British  Medical  Journal,  ISTs,  vol.  i.  p.  128. 


476  -  FRACTURES. 

lower  end  of  the  internal  malleolus ;  it  measured  one  inch  transversely 
and  "had  been  torn  off  the  posterior  surface  of  the  os  calcis  where  a 
cavity  could  be  felt.  The  whole  depth  of  the  bone  had  not  been  torn 
away,  but  only  the  upper  three-fourths,  and  the  inferior  edge  of  the 
fragment  was  tilted  backward.  The  usual  treatment  of  ruptured  tendo 
Achillis  was  adopted,"  and  eight  weeks  afterward  the  patient  was  able 
to  walk  without  limping  and  complained  only  of  some  loss  of  spring. 

I  have  seen  a  similar  fracture,  but  with  less  displacement  of  the  frag- 
ment, caused  by  jumping  from  a  boat,  the  fracture  apparently  occurring 
as  the  patient  alighted  on  his  toes.  In  another  the  patient  while  bend- 
ing forward  was  struck  upon  the  back  of  the  leg  by  a  falling  beam ; 
the  posterior  part  of  the  fragment,  as  shown  by  a  skiagram,  was  dis- 
placed upward  three  centimetres,  but  its  anterior  portion  remained  in 
contact  with  the  os  calcis  (Fig.  357). 

The  foot  should  be  maintained  in  the  position  of  complete  plantar 
flexion,  and  it  is  sometimes  advisable  to  flex  the  knee  also.  This  can 
be  done  by  a  plaster  dressing,  or  an  anterior  splint,  or  a  shoe  with  a 
cord  extending  from  its  heel  to  a  band  about  the  upper  part  of  the  leg 
or  the  lower  part  of  the  thigh.  Gussenbauer^  successfully  treated  a 
case  by  nailing  the  fragment  in  place. 

3.  FRACTURES  OF  THE  SCAPHOID. 

Those  which  were  formerly  deemed  very  rare  have  been  shown  by 
the  ;r-rays  to  be  not  very  uncommon.  Trippold  collected  43  cases 
including  2  seen  by  Jacobsthal ",  and  Deutschlander  ^  reported  5  per- 
sonal cases  in  3  of  which  the  fracture  was  caused  by  a  twist  of  the  foot 
in  young  girls.  Finsterer'*  collected  22  cases,  2  of  them  personal,  and 
Hoffmann  (Ibid.  p.  217)  added  another.  Of  these  latter,  5  were  caused 
by  direct  violence,  the  others  by  a  fall,  often  from  a  moderate  height, 
alighting  upon  the  ball  of  the  foot.  The  mechanism  is  apparently 
compression  between  the  head  of  the  astragalus  and  the  cuneiform, 
possibly  wdth  forced  flexion  of  the  medio-tarsal  joint. 

The  lesion  is  sometimes  a  crush  of  the  inferior  and  outer  portion, 
sometimes  a  splitting  iuto[two  or  more  fragments,  and  sometimes  only 
a  breaking  off  of  the  tubercle  (see  below).  The  symptoms  are  marked 
prominence  of  the  inner  portion  of  the  bone  on  the  dorsum  and  inner 
side  of  the  foot,  and  great  tenderness  when  this  prominence  is  pressed 
upon.  The  inner  side  of  the  foot  was  also  thought  to  be  shortened. 
Finsterer  thinks  a  characteristic  symptom  is  the  fact  that  while 
longitudinal  compression  of  the  foot,  from  the  toes  to  the  heel,  causes 
great  pain,  the  weight  of  the  body  in  standing  on  the  foot  causes  much 
less.  Two-thirds  of  the  cases  were  only  recognized  after  a  long  inter- 
val with  the  aid  of  the  a-rays. 

The  treatment  suggested  is  to  press  the  mesial  fragment  back  into 

1  Gussenbauer :  Centralblatt  fur  gesammte  Therapie,  June,  1888. 

2  Jacobsthal:  Ztlblatt  fiir  Chir.,  1907,  p.  604. 

3  Deutschlander :  Arch,  fiir  klin.  Chir.,  1907,  vol.  83,  p.  55. 
*■  Finsterer:  Beitrage  zur  klin.  Chir.,  1908,  vol.  59,  p.  99. 


FRACTURES  OF   THE  BONES  OF   THE  FOOT. 


477 


place  while  the  gap  between  the  astragalus  and  the  c-uneiform  is  en- 
larged by  traction  on  and  abduction  of  the  front  of  the  foot.  In  two 
cases  Deutschlander  removed  the  bone. 

Some  of  the  old  cases  showed  marked  evidences  of  chronic  arthritis 
in  the  medio-tarsal  joint. 

Haglund^  describes  fracture  of  the  tubercle  of  the  scaphoid  caused  in 
adolescents  by  muscular  action,  dancing;  he  says  it  may  result  promptly 
in  pes  valgus.  The  occasional  presence  of  a  sesamoid  bone  in  the 
tendon  of  the  tibialis  posticus  (os  tibiale  externum)  may  be  mistaken 
for  fracture  of  the  tubercle.  (Cf.  Gunther:  Zeifschft.  fiir  Rontgenkunde, 
xiii,  6;  Lapointe:  Arch.  qen.  de.  Chir.,  1911,  v,  6;  Mouchet:  Bull. 
Soc.  de  Chir.,  1913,  p.  1170.) 

4.  FRACTURE  OF  THE  CUBOID. 

The  only  case  of  which  I  know  is  the  one  shown  in  Fig.  .358,  a 
patient  of  the  Hudson  Street  Hospital.    The  fracture  was  caused  by  a 


Fig.  358. 


Fracture  of  cuboid. 


blow  on  the  outer  side  of  the  foot;  crepitus  was  distinct  on  pressure  of 
the  fragment  against  the  cuboid. 

Gontermann^  reported  a  ease  in  which  the  fracture  was  caused  by  the 
direct  pressure  of  the  edge  of  a  wagon-wheel.  The  symptoms  noted 
were  swelling  and  pain  on  pressure.  The  a,--rays  showed  a  fracture 
passing  through  the  bone  from  before  backward. 

It  is  claimed  that  the  .r-rays  have  disclosed  a  number  of  fractures, 
generally  marginal,  either  alone  or  in  combination  witli  those  of  other 
tarsal  bones,  hut  sucii  ob.servations  taken  after  the  lapse  of  considerable 
periods  of  time  must  be  viewed  with  distru.st.  The  possible  presence  at 
the  outer  side  of  the  cuboid  of  the  supposed  sesamoid  bones  in  the  tendon 
of  the  peroneus  longus,  the  os  vesalianum,  and  the  os  peroneum,  ami  of 
the  calcaneum  secundum  in  the  angle  between  the  cuboid,  calcanenni, 
astragalus,  and  scaphoid  must  be  borne  in  mind  in  interpreting  skiagrams. 

1  Ilaglund:  Zentralbliitt  fiir  f'liir.,  1907,  p.  327. 

2  Gonterniann :  Arch,  fiir  kliii.  Cliir.,  vol.  xci.  p.  186. 


478  FRACTURES. 

5.  FRACTURE    OF   THE    FIRST   CUNEIFORM. 

Els^  reports  a  case  of  avulsion  of  the  portion  of  the  first  cuneiform 
(and  also  possibly,  I  think,  of'the  first  metatarsal),  to  which  the  tendon 
of  the  tibialis  anticus  is  attached.  The  cause  was  forced  passive  flexion 
of  the  ankle  with  great  pain  and  the  sensation  of  something  snapping; 
also  dorsal  dislocation  of  the  toes.  The  patient  was  first  seen  nine  weeks 
later,  when  two  fragments,  a  centimetre  apart,  could  be  felt  in  the  line 
of  the  tendon  at  and  below  the  edge  of  the  head  of  the  astragalus;  the 
tendon  could  be  recognized  above  but  not  below  them.  There  was  a 
distinct  tendency  to  flattening  of  the  arch. 

6.  FRACTURE  OF  THE  SECOND  CUNEIFORM. 

Minguet  {Arch,  de  Med.  et  de  Pharm.  mil,  December,  1912)  reports 
a  Y-shaped  fracture  of  the  second  cuneiform  caused  by  the  fall  of  a 
horse  in  which  the  rider's  foot  was  caught  under  it. 

7.  FRACTURES  OF  THE  METATARSAL  BONES. 

These  were  formerly  thought  to  be  usually  the  result  of  direct  vio- 
lence, and  consequently  often  associated  with  contusion  or  laceration 
of  the  skin,  even  when  the  fracture  was  not  compound.  But  Robert 
Jones'"  broke  his  fifth  metatarsal  near  its  base  while  dancing,  and 
within  a  few  mouths  subsequently  saw  three  cases  similarly  produced. 
And  Tobold^  reports  over  seven  hundred  cases  observed  in  soldiers, 
almost  all  caused  by  indirect  violence,  as  marching,  jumping,  etc. 
The  second  was  the  one  most  frequently  broken,  then  the  thnxl.  Lilieu- 
feld^  has  seen  several  cases  of  fracture  of  the  extreme  tip  of  the  base 
of  the  fifth  metatarsal  caused  by  inversion  of  the  foot,  presumably 
through  the  pull  of  the  peroneus  brevis,  and  Wharton  ^  reports  three, 
caused  by  a  twist  of  the  foot  in  two  and  by  a  fall  in  one. 

There  is  but  little  tendency  to  displacement  except  when  several 
bones  are  broken  at  the  same  time,  and  the  usual  displacement  is  of 
the  broken  end  of  either  fragment  toward  the  dorsum  of  the  foot. 

The  diagnosis  is  made  by  localized  pain,  abnormal  mobility  and 
crepitus  when  the  first  or  fifth  is  broken,  and  pain  when  the  corre- 
sponding toe  is  pressed  bodily  backward  against  the  metatarsus. 

A  simple  fracture  is  not  a  serious  injury,  its  course  is  uncomplicated, 
its  result  favorable  ;  but  a  compound  fracture  may  lead  to  much  bur- 
rowing of  pus,  necrosis  of  the  fragments,  and  grave  inflammatory  com- 
plications, and  the  treatment  should  be  directed  actively  to  their 
prevention ;  if  suppuration  becomes  profuse  the  freest  possible  drainage 

1  Els:   Deutsche  Zeitschrift  fiir  Chir.,  1910,  cvi,  p.  610. 

2  Jones:  Annals  of  Surgery,  June,   1902. 

3  Tobold:  Deutsche  militarilrztl.  Zeitschrift,  1903,  Part  9,  abst.  in  Centralblatt  fiir 
Chir.,  1904,  p.  4.39. 

*  Lilienfeld:  Arch,  fiir  klin.  Chir.,  vol.  l.xxviii,  p.  929. 
5  Wharton:  Annals  of  Surgery,  May,   1908,  p.  824. 


FRACTURES  OF   THE  BONES  OF   THE  FOOT.  479 

should  be  provided  and  counter-openings  made  on  the  sole  or  dorsum 
as  the  case  may  require. 

The  hmb  and  foot  may  be  supported  upon  a  molded  splint  of  plas- 
ter, felt,  or  pasteboard,  and  secured  to  it  with  a  roller-bandage.  In 
compound  fracture  the  gauze  dressings  will  immobilize  the  fragments 
sufficiently. 

8.  FRACTURES  OF  THE  PHALANGES. 

These  are  caused  by  direct  violence  and  are  usually  compound,  and, 
as  in  similar  injuries  of  the  band,  may  be  the  starting-jwint  of  very 
serious  inflammatory  complications.  Immersion  of  the  foot  in  a  bath 
containing  1  or  2  per  cent,  of  carbolic  acid  once  or  twice  daily  for  an 
hour  each  time  is  a  valuable  means  of  arresting  commencing  inflam- 
mation. 

The  dressings  of  a  compound  fracture  will  immobilize  the  toe  suffi- 
ciently, and  in  a  simple  fracture  it  is  usually  sufficient  to  place  the  foot 
on  a  splint.  If  it  is  thought  desirable  the  toe  itself  may  be  steadied 
by  strips  of  adhesive  plaster  applied  longitudinally  to  its  dorsum  and 
sides,  or  it  may  be  made  fast  to  the  adjoining  ones. 

9.  FRACTURE  OF  A  SESAMOID  OF  THE  GREAT  TOE. 

Miiller^  reports  a  personal  case  and  collects  15  others.  The  first 
was  reported  by  Schunke  in  1901.  The  correctness  of  the  diagnosis 
was  questioned  in  5  of  the  cases  because  the  a;-rays  showed  a  similar 
partition  of  the  sesamoid  of  the  other  foot.  Miiller  quotes  Stumme  as 
showing  by  experiment  that  the  inner  sesamoid  could  be  broken  by 
dorsal  flexion  and  abduction  of  the  toe.  The  cause  in  the  reported  cases 
was  a  fall  upon  the  foot  or  a  blow  upon  the  toe.  The  late  symptoms 
were  persistent  soreness  and  pain  in  walking.  In  Miiller's  case  the 
fracture  was  transverse.  In  4  cases  the  bone  was  excised,  two  years 
after  the  accident  in  Miiller's. 

1  Miiller:  Annals  of  Surgery,  1912,  Iv.  101. 


DISLOCATIONS. 


(481) 


CHAPTER    XXVII. 

GENERALITIES. 

A  DISLOCATION  IS  a  permanent,  abnormal,  total  or  partial  displace- 
ment from  each  other  of  the  articular  portions  of  the  bones  entering 
into  the  formation  of  a  joint. 

The  term  diastasis  is  employed  to  indicate  a  direct  separation,  tem- 
porary or  permanent,  of  articular  surfaces,  without  lateral  gliding  of 
one  upon  the  other,  as  when  the  pubic  bones  separate  at  the  symphysis, 
or  the  tibia  and  fibula  are  torn  apart,  or  in  some  injuries  of  the  spinal 
column. 

If  the  displacement  is  only  momentary,  the  parts  immediately  return- 
ing to  their  normal  relations,  the  injury  is  classed  as  a  sprain. 

When  a  coexisting  wound  of  the  soft  parts  establishes  communication 
between  the  outer  air  and  the  cavity  of  the  joint,  the  dislocation  is  said 
to  be  compound  ;  and  when  there  exist  associated  lesions  of  the  joint  or 
neighboring  tissues  so  extensive  or  peculiar  as  to  present  special  indi- 
cations or  create  special  difficulties  in  treatment,  such  as  fracture  or 
laceration  of  vessels,  nerves,  or  integuments,  it  is  said  to  be  complicated  ; 
under  other  circumstances  it  is  described  as  simple. 

When  the  articular  surfaces  are  so  far  displaced  that  they  no  longer 
touch  each  other,  or  that  they  touch  only  by  their  edges,  the  dislocation 
is  said  to  he  complete;  if  the  displacement  is  less,  it  is  called  an  incom- 
plete dislocation  or  subluxation.  Incomplete  dislocations  are  frequent 
in  the  ginglymoid  and  arthrodial  joints,  and  the  controversy  as  to  their 
frequency  or  infrequency  in  the  enarthroses  has  arisen  not  from  any 
doubt  as  to  the  nature  of  the  new  relations  of  the  articular  surfaces  to 
each  other  or  of  the  extent  of  the  displacement,  but  solely  from  differ- 
ences in  definition,  some  authors  maintaining  that  only  those  dislocations 
should  be  deemed  complete  in  which  the  head  of  the  bone  has  entirely 
left  its  bony  socket,  and  all  those  incomplete  in  whicli  any  portion  of 
the  head  remains  within  the  area  bounded  by  the  rim  of  the  socket, 
whether  portions  of  the  articular  surfaces  are  in  contact  with  each  other 
or  not.  Under  that  definition  many  dislocations  of  the  shoulder  and 
of  the  hip  would  probably  have  to  be  classed  as  incomplete,  if  the  exact 
relations  of  the  bones  could  be  determined ;  and  as  such  accuracy  of 
diagnosis  would  rarely  be  attainable,  and  the  doubtful  cases  would  not 
differ  clinically  from  those  in  which  the  displacement  is  greater,  the 
adoption  of  such  a  classification  would  serve  only  to  embarrass  and 
obscure.  It  seems  to  me  much  simpler  and  more  practical,  even  if 
somewhat  arbitrary,  to  call  all  traumatic  dislocations  of  the  hip  and 
shoulder  complete  in  which  the  centre  of  the  head  of  the  bone  has 
passed  beyond  the  rim  of  the  socket.  The  incomplete  dislocations 
would  then  be  exceptional,  practically  only  those  in  which  a  portion  of 
the  rim  of  the  socket  is  broken  off  and  pushed  aside  by  the  displaced 

(483) 


484  DISLOCATIONS. 

head,  as  in  a  case  mentioned  by  Robert  ^  in  an  animated  discussion  of 
this  subject  before  the  Societe  de  Chirurgie. 

In  the  great  majority  of  cases  the  dislocation  is  of  a  single  joint  only, 
but  occasionally  two  or  more  joints  may  be  simultaneously  dislocated, 
and  the  injury  is  then  said,  according  to  circumstances,  to  be  bilateral, 
double,  or  multiple.  When  a  symmetrical  bone,  having  joints  on  both 
sides  of  the  median  line  of  the  body,  as  the  lower  jaw  or  a  vertebra, 
suffers  dislocation  of  these  joints,  the  injury  is  called  bilateral  or  double, 
and  the  same  terms  are  also  applied  to  symmetrical  dislocations  on  op- 
posite sides  of  the  body,  as  of  both  shoulders  or  both  hips.  When 
both  ends  of  a  bone  are  dislocated,  as  has  been  observed  in  the  clavicle, 
ulna,  and  fibula,  the  dislocation  is  said  to  be  double  or  total. 

Multiple  dislocations  are  those  in  which  two  or  more  bones  are  simul- 
taneously dislocated,  as  two  fingers,  a  shoulder  and  a  hip.  Some 
authors  include  under  this  term  those  dislocations  which  others  term 
total. 

A  method  of  nomenclature  accurately  descriptive  of  the  different 
varieties  of  dislocation  has  not  been  established.  As  a  general  rule, 
subject,  however,  to  some  exceptions,  the  bone  which  is  more  distant 
from  the  trunk  or  median  line  of  the  body,  the  one  that  is  generally 
moved  upon  the  other,  is  said  to  be  dislocated ;  thus  a  dislocation  at  the 
hip,  at  the  shoulder,  is  called  a  dislocation  of  the  femur,  of  the  humerus. 
Or  the  joint  alone  is  named,  as  a  dislocation  of  the  elbow,  of  the  hip, 
of  the  shoulder.  As  an  example  of  the  exceptions  may  be  mentioned 
dislocation  of  the  outer  end  of  the  clavicle,  a  terra  universally  preferred 
to  dislocation  of  the  acromion. 

The  same  lack  of  uniformity  appears  in  the  names  given  to  the  vari- 
ous dislocations  that  may  occur  at  the  individual  joints,  and  the  prac- 
tice has  grown  up  of  using  in  each  case  such  a  name  as  may  most 
readily  and  accurately  indicate  either  the  general  character  of  the  dis- 
placement or  some  important  special  feature  connected  with  it.  When 
the  name  of  the  joint  is  used,  and  a  term  indicating  direction  is  added, 
as  dislocation  of  the  elbow  backward,  forward,  to  the  inner  or  to  the 
outer  side,  the  latter  denotes  the  direction  in  which  the  distal  member 
of  the  joint  has  been  displaced.  Whenever  the  use  of  the  name  of  the 
joint  would  give  rise  to  ambiguity,  it  is  common  to  prefer  the  name  of 
one  of  the  bones  constituting  it,  as  a  dislocation  of  the  radius  and  ulna 
backward,  instead  of  dislocation  of  the  elbow  backward.  Strictly  speak- 
ing, it  is  true  that  this  might  be  mistaken  for  a  dislocation  at  the  wrist, 
and  that,  therefore,  it  would  be  well  to  add  "  at  the  elbow,"  but  cus- 
tom has  so  well  established  the  meaning  of  the  different  terms  now  in 
use  that  in  practice  such  a  mistake  would  hardly  be  made.  Other  dis- 
locations, again,  have  received  names  denoting  the  relations  of  the  dislo- 
cated bone  to  certain  muscles  or  bones,  as  subcoracold  or  subpectoral 
dislocation  of  the  humerus,  and  dislocation  of  the  (head  of  the)  femur 
upon  the  dorsum  of  the  ilium  or  into  the  obturator  foramen. 

'Y\\e primitive  OY  primary  displacement  is  the  oue  immediately  effected 
by  the  causative  violence  which  produces  the  dislocation  ;  if  the  dislo- 
cated bone  afterward  shifts  to  another  position,  the  displacement  is  said 

'  Robert :  Bull,  de  la  Societe  de  Chirurgie,  January  19,  1853,  p.  389. 


GENERALITIES. 


485 


to  be  consecutive  or  secondary.  This  shifting  of  the  position  of  the 
dislocated  end  sometimes  has  very  im})ortant  consequences  as  regards 
treatment,  because  the  end  of  the  bone  may  thereby  be  removed  from 
its  position  opposite  the  rent  in  the  capsule  through  Mhicii  it  escaped 
from  the  cavity  of  the  joint,  and  it  may  need  to  be  brought  back  to 
that  position  before  it  can  be  replaced  in  the  joint. 

In  the  great  majority  of  cases  a  dislocation  is  produced  suddenly  by 
external  violence  or  by  muscular  action,  or  by  the  two  acting  together 
upon  a  healthy  joint,  and  when  thus  produced  it  is  called  traumatic. 
In  other  cases  the  joint  has  been  altered  by  disease  previous  to  the 
occurrence  of  the  dislocation,  and  this  latter  is  effected  by  the  gradual 
action  of  the  muscles  or  even  by  gravity  ;  these  are  known  as  sponta- 
neous, and  present  many  varieties.  (See  Chapter  XXXVI.)  A  third 
class,  congenital  dislocations,  is  composed  of  those  in  which  the  dislo- 
cation occurs  during  intra-uterine  life,  presumably  as  the  result  of  a 
malformation  or  defective  development.  Dislocations  produced  during 
delivery  are  traumatic.  The  second  and  third  classes  will  be  sepa- 
rately considered.     (See  Chapters  XXXV.  and  XXXVI.) 

Statistics.  Compared  with  other  surgical  injuries,  dislocations  are 
infrequent;  the  proportion  to  fractures  is  about  1   to  10. 


Dislocations  at  the  Hudson  Street  Hospital,   New  York,  1894-1905. 
Hospital  and  Dispensary. 

....  191 


Hip;  dorsal 

thyroid 

Knee 

Semilunar  cartilage    .    •    • 
Patella,    outward    .    .    .    . 

Head  of  fibula 

Ankle 

Astragalus 

Subastragaloid 

Metatarsus  and  phalanges , 


12 
13 

9 

1 

5 
5 

5 

17J 


Lower  jaw 

Vertebrae 

C'hondro-sternal       .    .    _■ 
Sacro-iliac  synchondrosis 


Lower  extremity,        89      5.82  per  cent. 


Clavicle,  outer  end    ...  69"] 

sternal  end 12 

Shoulder 617 

Elbow 156 

Head  of  radius  ^ 18 

Ulna,  upper  end  ^  .    .    .    .  13 

lower  end 

Carpus  

trapezium 

semilunar 5 

scaphoid 3 

OS  magnum 1 

Metacarpal      80 

Metacarpo-phalangeal    and 

phalangeal 378  J 

61] 

Jl 

1527 


7  y    Upper  extrenuty,  1368 
1 


89.59  per  cent. 


Head  and  trunk,  70      4.58  per  cent. 


1  Including  cases  with  associated  fracture. 


486 


DISLOCATIONS. 


Table  of  400  Recent  Traumatic  Dislocations  (Kronlein).^ 
Hospital  and  Polyclinic. 


Joints. 


Hip 

Knee 

Foot 

Metatarso-phalangeal 

Shoulder \ 

I 

Elbow 

Wrist 

Metacarpo-phalangeal 
Interphalangeal   .   . 
Sterno-clavicular     .   . 
Acrdmio-clavicular    . 

Lower  jaw \ 

Cervical  vertebrae    .  . 


Kind. 


Unilateral 
Bilateral  . 


Iliac  .  .  . 
Obturator 
Pubic  .  .  . 
Lateral  .  . 
Patella  out-  \ 
ward) 
backward 

Subcoracoid   ) 
and  axillary  J 
Erecta    .   .   . 
Infraspinous 
Of  forearm  .  ) 
backward  J 
Of  radius 
Dorsal  of  ulna 


Sex. 

Age. 

M. 

F. 

0 

2 
2 

22 
9 

6 

1 
1 

"i 

44 

I 

"i 

2 

i 

2 

44 
5 

"s 

"3 

1 
1 
1 

"i 

1 

53 
2 

14 

1 
1 
4 
5 
2 

"i 

3 

0 

1 

i 

1 

44 

1 

5 

"8 
1 

"2 

"i 

48 
4 

"i 

1 

"4 
2 

iO 

1 

"i 
1 

"2 
35 

"i 
3 

"3 
"i 

0 

1 

s 
"i 

1 

19. 

1 

i 

2 
1 

4 
2 
1 
4 
2 

1 
3 

180 

3 
1 

77 

9 
1 

23 
7 
4 

11 
2 

i 

336 

"i 

1 
1 

23 

17 
6 

"4 
1 
2 

2 
6 

64 

69 

88 

65 

60 

48 

23 

3 

400 

4( 

)0 

Totals. 


Percentages  of 
frequency. 


7   1.7 


207  51.7 


Lower 

extremity, 

20  =  5 


400 


Upper 
n  Q      j-  extremity, 
an  369  =  92.2 


Trunk, 
11  =  2.8 


The  following  table  summarizes  the  other  two  with  Malgaigne's 
statistics  of  the  Hotel-Dieu  : 


Malgaigne,  hospital 

Kronlein,  hospital  and  polyclinic  . 
Stimson,  hospital  and  dispensary  . 


Cases. 


491 
400 
1527 


Upper  extremity, 

85.7  per  cent. 

92.2 

89.59 


Lower  extremity. 


12.6  per  cent. 
5 
5.82      " 


Trunk. 

1.6  percent. 

2.8 
4.58      " 


These  tables  show  the  great  relative  frequency  of  dislocations  of  the 
upper  extremity  as  compared  with  those  of  the  lower.  Each  set  of 
statistics  shows  that  dislocation  of  the  shoulder  is  far  more  common 
than  that  of  any  other  joint,  and  that  next  in  frequency  come  disloca- 
tions of  the  elbow.  These  two  dislocations  may  be  estimated  as 
together  comprising  from  two-thirds  to  three-fourths  of  all  cases, 
excluding  the  phalanges. 

As  between  males  and  females,  Malgaigne  and  Gurlt  found  the 
injury  three  times  as  frequent  in  the  former  as  in  the  latter;  Kronlein 
found  it  five  times  as  great.  Dislocations  of  the  lower  jaw  are  an  ex- 
ception, being  four  times  (Kronlein)  as  frequent  in  women  as  in  men. 

Age.  No  age  is  exempt;  dislocations  have  occurred  as  early  as  the 
moment  of  birth  and  as  late  as  the  age  of  ninety  years.  The  relative 
liability  to  the  injury  at  different  ages  is  shown  not  by  simply  com- 
paring the  number  of  cases  observed  at  those  ages,  but  by  also  com- 

'  Kronlein :  Deutsche  Chirurgie,  Lief.  26,  p.  5. 


GENERALITIES. 


487 


paring  these  numbers  with  the  number  of  people  af  those  ages  living 
in  the  community  where  the  observation  is  made.  This  comparison 
has  been  made  by  Kronlein  for  Berlin,  with  the  following  results  : 

Frequency  of  Dislocations  at  Diffebent  Ages. 


Absolute  frequency 

Relative  number  of  people  living 

Relative  frequency  as  computed  for  equal ) 
numbers  of  people j 


1-10    11-20   21-30    31-40   41-50   51-60   61-70   71-80 


44 
1872 


69 
1620 

18 


2529 
15 


65 
1679 

16 


60 
940 


48        23  3 

599       282    i  117 

35 


35 


10  + 


From  this  it  appears  that  a  smaller  proportion  of  individuals 
between  the  ages  of  one  and  ten,  and  seventy-one  and  eighty  years 
receive  dislocations  than  in  any  other  decade  of  life ;  and  the  highest 
proportions  are  found  between  the  ages  of  fifty-one  and  sixty  and 
sixty-one  and  seventy.  It  is  further  to  be  noticed  that  dislocation  of 
the  shoulder  is  very  rare,  and  that  of  the  elbow  very  common,  before 
the  age  of  twenty-one  years.  Kronlein's  table  shows  that  of  207  cases 
of  the  shoulder,  in  only  two  were  the  patients  less  than  twenty-one 
years  old,  and  that  of  109  cases  of  the  elbow  80  were  no  older,  the  age 
in  31  being  between  one  and  ten  years,  and  in  49  between  eleven  and 
twenty  years.  Compared  with  fractures,  it  appears  that  the  liability 
to  dislocation  is  least  during  those  periods  of  life  in  which  the  liability 
to  fracture  is  greatest — that  is,  in  infancy  and  youth  and  in  old  age; 
the  latter  part  of  this  statement  may  need  some  modification,  for  while 
dislocations  are  rare  after  the  age  of  seventy,  they  are  relatively  fre- 
quent in  the  preceding  decade.  The  liability  to  each  increases  from 
adolescence  through  middle  life. 


CHAPTEE  XXVIII. 

ETIOLOGY  AND  MECHANISM. 

Predisposing  Causes ;  Immediate  Causes ;  Recurrent  or  Habitual  Dislocations. 

The  causes  of  dislocation  may  be  grouped  in  two  classes  :  a.  Pre- 
disposing ;  6.  Immediate  or  determining. 

A.  Predisposing-  Causes. 

These  are  found  in  certain  normal  differences  of  form  and  function 
characterizing  certain  joints,  and  in  accidental  or  pathological  conditions 
that  sometimes  arise. 

The  joint  which  is  most  frequently  dislocated  is  the  shoulder-joint, 
and  it  differs  normally  from  others  in  the  wide  range  and  variety  of 
motion  made  possible  by  its  form,  the  laxity  of  its  capsule,  and  the 
absence  of  any  firm  ligament  to  hold  the  bones  closely  together.  A 
wide  range  of  motion  in  one  direction  is  not  necessarily  a  circumstance 
favoring  dislocation  ;  on  the  contrary,  it  may  protect  against  it  by 
making  it  difficult  to  bring  into  action  the  fulcrum  which  is  furnished 
by  the  edge  of  the  bone  when  it  arrests  the  motion.  In  a  young 
healthy  person  the  elbow  or  knee  cannot  be  dislocated  by  flexion, 
because  the  motion  is  finally  arrested  by  broad  contact  of  the  soft  parts, 
not  by  the  edge  of  the  joint;  while,  on  the  other  hand,  iu  each  case 
extension  is  limited  by  the  structures  of  the  joint  itself,  and  hyper- 
extension  at  once  favors  dislocation  by  rupturing  those  structures.  A 
long  range  of  motion  in  one  plane  does  not  make  the  joint  insecure  so 
long  as  the  two  bony  surfaces  rest  squarely  against  each  other,  as  they 
do  in  the  hinge-joints ;  but  when  the  change  of  position  makes  this 
contact  oblique,  as  in  abduction  of  the  arm,  a  displacing  force  exerted 
in  the  direction  of  the  long  axis  of  the  bone  is  resisted  onlv  by  the 
capsule.  Under  certain  conditions,  therefore,  it  may  be  said  that  free- 
dom of  motion  in  a  joint  diminishes,  and  limitation  of  motion  increases, 
the  liability  to  dislocation. 

Dropsy  of  some  joints  favors  dislocation  by  removing  the  obstacle 
which  the  necessity  of  creating  a  vacuum  between  the  articular  surfaces 
would  otherwise  interpose.  (See  Chapter  XXXVL,  Dislocations  by 
Distention.) 

The  destruction  of  the  ligaments  by  violence  or  disease,  and  frac- 
ture or  disease  of  the  bony  constituents  of  the  joint,  favor  dislocation, 
and  the  fracture  of  an  associated  or  parallel  bone  may  have  the  same 
effect,  as  fracture  of  the  ulna  favors  dislocation  of  the  head  of  the 
radius. 

(488) 


ETIOLOGY  AND  MECHANISM.  4^9 


B.  Immediate  or  Determining  Causes. 

A  bone  may  be  dislocated  by  (1)  external  violence  apj)lied  {(t)  directly 
to  it  at  or  near  its  end,  or  (6)  indirectly  and  at  a  distance  from  its  end ; 
(2)  by  mnscular  action. 

1,  External  Violence,  Dislocations  by  direct  violence  are  rare,  es]")e- 
cially  if  the  class  is  restricted  to  those  cases  in  \vhi(!h  the  violence  falls 
upon  only  one  of  the  bones  forming  the  joint  and  forces  it  dii'ocllv 
away  from  the  other.  Thus,  the  head  of  the  humerus  has  been  driven 
backward  (subspinous  dislocation)  by  a  blow  of  the  list  (Busch)  or  by 
a  fall  in  which  the  front  of  the  shoulder  struck  against  the  corner  of" 
a  table  (Kronlein),  or  inward  by  a  fall  upon  the  outer  side  of  the 
shoulder,  or  even  downward  into  the  axilla  by  a  force  received  upon 
and  first  breaking  the  acromion  (Kronlein,  Stimson). 

In  dislocations  by  indirect  violence  the  mechanism  may  vary  greatly. 
The  force  in  some  cases  is  exerted  directly  along  the  long  axis  of  the 
bone  while  the  limb  is  in  a  position  in  Avhich  the  articular  surfaces  do 
not  rest  squarely  upon  each  other,  and  the  head  of  the  bone  is  driven 
out  of  its  socket,  as  in  some  dislocations  of  the  shoulder  b}'  a  fall  upon 
the  outstretched  (abducted)  arm  or  by  muscular  action,  or  in  disloca- 
tion of  the  outer  end  of  the  clavicle  by  a  fall  upon  the  shoulder.  The 
mechanism  is  similar  to  that  of  the  first  form  of  dislocation  by  direct 
violence  mentioned  above.  Or  a  much  slighter  force,  favored  by 
conditions  of  leverage  established  at  the  joint,  tears  the  capsule  or 
a  ligament  and  produces  a  dislocation.  This  is  the  most  common 
mechanism.  The  conditions  of  leverage  are  found  at  all  points  where 
normal  movements  are  arrested  or  no  movement  permitted.  The  head 
or  neck  of  a  moving  bone  is  arrested  by  the  edge  of  the  corresponding 
articular  cavity,  or  by  a  projecting  point  of  bone,  or  by  a  tense  liga- 
ment or  portion  of  capsule ;  this  at  once  becomes  a  new  centre  of 
motion,  a  fulcrum,  and,  the  force  continuing  to  act  at  the  end  of  the 
bone  or  limb  (the  long  arm  of  the  lever),  the  head  of  the  bone  (or  short 
end  of  the  lever)  is  forced  away  abnormally. 

When  the  force  is  exerted  in  a  direction  in  which  normally  no  motion 
is  permitted,  as  laterally  at  the  elbow,  ankle,  or  knee,  it  meets  at  once 
with  greater  resistance  than  that  habitually  found  at  the  extremes  of 
normal  ranges  of  motion,  and  if  it  is  great  enough  to  overcome  this 
resistance  it  is  more  likely  to  cause  in  addition  other  and  pci-haps 
extensive  injuries  of  the  soft  parts  or  of  the  bones. 

Violence,  then,  acting  in  a  given  manner,  may  cause  a  fracture,  a 
dislocation,  or  a  sprain  according  to  its  force,  the  strength  of  the  resist- 
ance offered  by  the  ligaments  and  the  bones  to  which  they  are  attached, 
and  the  j)rolongation  of  its  action. 

2.  Muscular  Action.  Contraction  of  the  corresponding  nniscles  can 
cause  the  dislocation  of  a  sound  joint  in  either  of  two  Mays  :  it  can,  by 
rapidly  moving  the  limb,  communicate  to  it  a  momentum  which  acts 
in  the  same  manner  as  external  violence  and  produces  a  dislocation 
when  the  normal  limit  of  the  range  of  motion  is  reached  and  condi- 
tions of  leverage  are  established.  A  case,  ])rol)ably  ol'  this  kind,  was 
35 


490  DISLOCATIONS. 

observed  by  Sedillot :  ^  a  woman,  forty-six  years  old,  who  dislocated  her 
shoulder  by  raising  her  arm  to  strike  a  blow.  Or,  secondly,  the  mus- 
cular contraction  acts  like  external  violence  received  at  or  near  the  end 
of  the  bone,  or  transmitted  along  its  longitudinal  axis,  and  draws  the 
bone  out  of  its  socket.  For  this  it  is  essential  that  one  or  two  muscles 
should  contract  violently  while  the  others  that  normally  act  upon  the 
joint  remain  passive,  or  that  the  limb  should  be  in  such  a  position  that 
the  line  of  traction  of  the  muscles  is  nearly  parallel  to  the  opposing 
articular  surface.  Instances  of  this  kind  are  common  at  some  joints  ; 
dislocation  of  the  lower  jaw  is  commonly  caused  by  muscular  action 
in^  yawning,  laughing,  or  vomiting,  and  others  have  been  caused  in  like 
manner  at  the  shoulder  and  hip,  and,  very  exceptionally,  at  other 
joints.     As  illustrative  examples  may  be  mentioned  the  following : 

A  man,  fifty-one  years  old,  dislocated  both  shoulders  (subcoracoid) 
by  drawing  himself  up  with  his  hands ;  a  painter  dislocated  his  shoul- 
der while  painting  a  ceiling;  a  woman,  by  trying  to  lift  a  heavy  object 
from  a  shelf;  a  man,  by  trying  to  lift  at  arm's  length  a  heavy  book 
from  the  floor ;  and  a  woman,  by  carrying  a  heavy  load  upon  her  head 
with  both  arms  uplifted. 

Many  cases  have  been  reported  in  which  dislocation  has  been  caused 
by  the  convulsive  contractions  of  individuals  affected  with  epilepsy, 
tetanus,  or  ursemia,  or  poisoned  with  strychnine.  In  many  of  the 
cases  reported  as  such  the  dislocation  may  have  been  caused  by  vio- 
lence received  in  falling  during  a  fit  or  by  striking  the  limb  against 
some  object,  but  in  a  number  of  them  the  history  positively  establishes 
the  absence  of  any  other  cause  than  the  contraction  of  the  muscles. 

In  these  cases,  as  in  fractures  by  muscular  action,  it  is  unnecessary 
to  suppose,  and  unwarranted  to  claim,  that  the  strength  of  the  capsule 
or  ligaments  is  less  than  usual,  or  that  the  structure  of  the  joint  varies 
from  the  normal  in  such  a  way  as  to  facilitate  the  production  of  the 
dislocation. 

The  power  of  voluntary  dislocation  of  one  or  several  joints  has  been 
occasionally  observed.  In  a  large  proportion  of  the  cases  its  appear- 
ance has  followed  the  occurrence  of  a  traumatic  dislocation  of  the  same 
joint,  but  in  a  few  instances  the  history  of  the  individual  contained  the 
record  of  no  traumatism  or  diseased  condition  to  which  the  peculiarity 
could  be  referred. 

C.  Recurrent  or  Habitual  Dislocations. 

Individuals  are  occasionally  observed  in  whom  dislocation  of  some 
one  joint,  commonly  the  shoulder,  but  also  the  hip,  jaw,  and  clavicle, 
frequently  recurs  under  the  influence  of  some  slight  cause,  and  who 
have  acquired  this  liability  as  the  result  of  an  ordinary  traumatic  dis- 
location, or  of  paralysis  of  one  or  more  of  the  muscles  of  the  joint,  or 
of  fracture.  The  first  class  will  be  considered  in  Chapter  XXIX. ;  of 
the  others  the  following  case,  reported  by  Sir  Astley  Cooper,^  will 

'  Sedillot :  Diet.  Encyclopedique,  art.  Luxations,  p.  23. 
^  Cooper :  Dislocations  and  Fractures,  Am.  ed.,  1844,  p.  9. 


ETIOLOGY  A^D  MECHANISM.  491 

serve  as  an  illustration  :  "  A  gentleman  happened,  as  a  junior  officer 
on  board  his  ship,  to  be  placed  under  the  orders  of  one  of  the  mates 
when  the  captain  was  on  shore,  and  for  some  trifling  offence  was 
punished  in  the  following  manner :  his  foot  Avas  placed  upon  a  small 
projection  on  the  deck,  and  his  arm  was  lashed  tightly  toward  the  yard 
of  the  ship,  and  thus  kept  extended  for  an  hour.  When  he  returned 
to  England  he  had  the  power  of  readily  throwing  that  arm  from  its 
socket  merely  by  raising  it  toward  his  head,  but  a  very  slight  extension 
reduced  it ;  the  muscles  were  also  wasted,  as  in  a  case  of  paralysis." 

The  explanation  is  to  be  found  in  the  loss  of  support  occasioned  by 
the  diminution  of  the  tonicity  of  the  muscles  which  in  such  joints  as 
the  shoulder,  take  the  place  of  short,  firm  ligaments  and  hold  the 
articular  surfaces  in  contact  with  each  other,  a  loss  which  allows  the 
bones  to  be  separated  by  the  action  of  gravity,  or  by  an  effusion  into 
the  joint,  until  the  separation  is  arrested  by  the  capsule.  When  thus 
separated,  a  slight  force  is  sufficient  to  throw  the  head  of  the  humerus 
past  the  edge  of  the  glenoid  cavity  and  produce  a  dislocation  without 
rupture  of  the  capsule. 

The  cases  of  dislocation  due  to  limited  paralysis  of  peripheral  origin 
must  not  be  confounded  with  those  sometimes  accompanying  the 
arthropathies  that  complicate  some  paralyses  of  central  origin  and 
some  cases  of  central  nervous  disease  without  paralysis.  In  the  latter 
the  articular  portions  of  the  bones  are  absorbed  in  the  progress  of  the 
disease,  and  thus  even  a  joint  the  bones  of  which  are  normally  held 
close  together  by  ligaments  becomes  a  loose  one  by  loss  of  bone  sub- 
stance. Strictly  speaking,  such  cases  in  which  the  articular  end  of  the 
bone  has  been  entirely  absorbed  do  not  come  within  the  definition  of 
dislocation,  but  clinically  it  is  proper  and  convenient  so  to  designate 
them.     (See  Chapter  XXXVI.) 

The  unequal  growth  of  parallel  and  associated  bones,  tibia  and  fibula, 
or  radius  and  ulna,  may  cause  dislocation  at  one  or  the  other  end. 

•  Cooper  :  Dislocations  aud  Fractures,  Am.  ed.,  1844,  p.  9. 


CHAPTER  XXIX. 

PATHOLOGICAL   ANATOMY  IN  EECENT  DISLOCATIONS;  COMPLI- 
CATIONS; AND  THE  PPvOCESS  OF  EEPAIR  AFTER  REDUCTION. 

PATHOLOGICAL    ANATOMY. 

As  a  traumatic  dislocation  consists  in  the  forcible  overcoming  of  the 
normal  restraints  upon  the  motion  of  the  joint  in  one  or  more  direc- 
tions, restraints  offered  by  the  ligaments  and  capsule  of  the  joint,  it  is 
almost  invariably  accompanied  by  rupture  of  a  ligament  or  of  the  cap- 
sule. There  is  some  reason  to  think  that  dislocation  of  the  inferior 
maxilla  may  be  an  exception  to  this  rule,  but  the  lack  of  opportunities 
directly  to  examine  such  cases  leaves  the  question  in  doubt.  In  enar- 
throdial  joints,  especially  the  shoulder,  where  the  ligaments  are  loose 
and  where  the  bones  are  held  together  by  the  tonicity  of  the  muscles 
and  the  atmospheric  pressure,  such  a  change  as  dropsy  of  the  joint  may 
so  annul  the  efiPect  of  the  latter  agent  and  overcome  the  former  by  filling 
the  capsule  with  liquid  that  insinuates  itself  between  the  contiguous 
articular  surfaces,  that  the  head  of  the  bone  falls  away  from  its  socket 
and  the  joint  becomes  loose  like  that  of  a  flail ;  under  such  circum- 
stances dislocation  may  occur  without  rupture  or  laceration. 

The  capsule  of  an  enarthrodial  joint  is  torn  upon  the  side  toward 
which  the  distal  bone  is  displaced  ;  in  joints  of  other  forms  the  liga- 
ments may  be  broken  on  either  or  both  sides,  the  extent  and  character 
of  the  injury  varying  with  the  character  of  the  force.  The  rent  in  the 
capsule  may  be  limited  in  extent  and  simple  in  form,  merely  a  longi- 
tudinal or  transverse  slit,  or  it  may  be  irregular  or  may  even  involve 
the  entire  periphery.  Instead  of  suffering  a  rent,  the  capsule  may  be 
torn  away  from  the  bone,  sometimes  bringing  with  it  portions  of  the 
bone  itself  or  remaining  continuous  with  the  periosteum  stripped  up 
from  the  shaft.  Under  similar  conditions  the  position  of  the  rent  in 
the  capsule  is  very  constant,  for  it  is  determined  by  the  posture  of  the 
head  and  the  direction  of  the  force.  In  addition  to  the  laceration  of 
the  capsule  and  ligaments  produced  by  the  pressure  of  the  bone,  others 
may  be  caused  by  the  tearing  oflP  of  atitached  muscles  that  are  put  upon 
the  stretch  by  the  displacement.  This  may  be  eflPected  by  the  avulsion 
of  the  tuberosities  upon  which  the  muscles  are  inserted  ;  the  bone  yields, 
and  the  laceration,  starting  from  the  broken  surface,  extends  across  and 
through  the  adjoining  soft  parts.  This  is  a  frequent  accompaniment 
of  dislocation  forward  and  downward  of  the  shoulder ;  the  supra- 
spinatus  and  infraspinatus  muscles,  inserted  respectively  upon  the 
ujiper  and  middle  facets  of  the  greater  tuberosity  of  the  liiwnerus,  are 
put  upon  the  stretch  and  one  or  both  are  torn  away  from  the  bone. 

The  soft  parts  overlying  the  capsule  may  be  torn  by  extension  of  the 
(  492  ) 


COMPLICATIONS  OF  RECENT  DISLOCATIONS.  493 

rent  in  the  capsule  if  they  are  closely  adherent  to  tlie  latter,  or  by  the 
forcible  passage  through  them  of  the  displaced  bone.  The  surrounding 
muscles  on  the  side  toward  which  the  displacement  takes  place  may  be 
contused  or  torn  by  the  passage  of  the  bone,  and  those  upon  the  oppo- 
site side  by  being  put  upon  the  stretch.  Blood  is  freely  extravasated 
into  the  cellular  tissue  from  the  ruptured  vessels. 

The  cartilages  of  incrustation  may  be  bruised  and  sometimes  chipped 
in  the  passage  of  the  surfaces  across  each  other,  and  projecting  portions 
of  bone,  apophyses,  or  the  rim  of  an  orbicular  cavity  may  be  broken  off. 

The  bone  itself  seldom  passes  to  any  great  distance  from  its  normal 
position  ;  its  progress  is  arrested  by  the  ligaments  and  muscles  that 
remain  untorn  and  the  resistance  of  the  soft  parts  that  it  presses  upon, 
and  it  comes  to  rest  lying  directly  upon  the  adjoining  bone  or  with  some 
soft  parts  interposed.  Its  position,  as  taken  in  the  primary  displace- 
ment, may  be  changed  by  the  renewal  of  external  violence,  by  gravity, 
by  a  change  in  the  position  of  the  limb,  or  by  the  spasmodic  contrac- 
tion of  attached  muscles,  but  the  secondary  position  ("  consecutive 
displacement ")  is  habitually  determined  by  the  resistance  of  untorn 
ligaments  which  constitute  the  fulcrum  or  pivot  about  which  the  bone 
turns. 

COMPLICATIONS. 

Other  injuries,  and  severer  or  more  extensive  forms  of  those 
already  mentioned,  may  coexist  with  a  dislocation  as  complications. 
They  include  fracture  of  the  bone,  partial  or  complete  rupture  of 
large  bloodvessels  or  nerves,  and  extensive  laceration  of  the  soft 
parts.  To  constitute  a  ''complication"  of  the  dislocation  the  associ- 
ated injury  should  be  the  direct  or  consecutive  result  of  the  original 
violence  upon  adjoining  tissues,  and  should  create  special  indications 
for,  or  difficulties  in,  treatment.  A  fracture  of  the  leg  cansed  by  the 
same  fall  that  dislocates  the  shoulder  is  not,  in  this  sense,  a  ''  compli- 
cation "  of  the  dislocation  ;  but  a  fracture  of  the  ulna  accompanying 
dislocation  of  the  radius,  or  a  fracture  of  the  neck  of  the  humerus 
accompanying  dislocation  of  the  shoulder  is  a  complication,  for  the  two 
injuries  are  associated  in  their  origin  and  in  their  treatment. 

Bones.  Not  all  fractures  that  coexist  with  dislocation  of  even  the 
same  bone  are  necessarily  to  be  deemed  complications,  since  some  habit- 
ually accompany  certain  dislocations,  may  even  not  be  recognizable 
(•linically,  and  neither  receive  nor  require  special  treatment.  Such  are 
fractures  of  apophyses  or  tubercles  to  which  muscles  are  attached,  and 
some  fractures  of  a  portion  of  the  articular  end  of  the  bone  or  of  the  rim 
of  an  orl)icular  cavity.  In  others  the  dislocation  is  rather  to  be  deemed 
a  complication  or  incident  of  the  fracture,  since  it  is  made  possible  by 
it,  as  in  some  fractures  of  the  vertebrae  and  in  fracture  of  the  olecranon 
with  displacement  forward  (or  upward)  of  the  radius  and  ulna. 

Relatively  common  are  those  in  which  the  force  is  exerted  through 
the  head  of  the  bone  upon  the  margin  of  the  opposing  articular  sur- 
face, breaking  off  the  latter  ;  the  dislocated  bone  leaves  the  joint  through 
the  gap  thus  created,  driving  the  fragment  before  it,  or  else  tears  the 
capsule  and  escapes  in  the  usual   manner.     The  commonest  examples 


494  DISLOCATIONS. 

of  this  kind  are  found  in  fractures  of  portions  of  the  rim  of  the  glenoid 
and  cotyloid  cavities,  and  some  fractures  at  the  ankle  with  dis- 
placement of  the  astragalus.  Others,  that  are  closely  analogous,  are 
fractures  of  the  coronoid  process  of  the  ulna  or  of  the  head  of  the 
radius,  or  of  both,  in  dislocation  backward  of  both  bones. 

Bruising  or  deep  indentation  of  the  head  of  the  bone  by  impact  upon 
the  edge  of  the  socket  has  been  noted  several  times  at  the  shoulder  and 
once  by  myself  at  the  hip.  It  cannot  be  recognized  clinically  and  is 
not  known  to  have  important  consequences,  but  when  the  impact  is 
along  the  anatomical  neck  of  the  humerus  it  may  detach  the  head,  and 
in  two  cases  ^  the  head  of  the  femur  has  been  split  vertically  ;  in  a  third  ^ 
the  head  and  neck  were  split  longitudinally,  apparently  after  disloca- 
tion had  taken  place. 

A  very  rare  complicating  fracture  is  that  of  the  central  part  of  the 
acetabulum  when  the  head  of  the  femur  is  driven  through  it  into  the 
cavity  of  the  pelvis  by  great  violence. 

Much  more  common,  but  seldom  deserving  to  be  classed  as  compli- 
cations, are  those  fractures  by  avulsion,  already  referred  to,  in  which, 
ligaments  or  muscles  being  put  upon  the  stretch,  the  bony  prominences 
to  which  they  are  attached  are  torn  oif.  Some  of  them  may  be  looked 
upon  as  frequent  accompaniments  of  certain  dislocations,  for  example, 
fracture  of  the  greater  tuberosity  of  the  humerus  in  dislocation  of  the 
shoulder  forward  and  downward,  and  fracture  of  the  internal  epicon- 
dyJe  in  dislocation  of  the  elbow. 

The  form  in  which  the  complication  most  seriously  aflPects  the  treat- 
ment and  prognosis  is  that  in  which  the  bone  is  broken  completely 
across  near  the  dislocated  end.  The  commonest  examples  are  found 
at  the  shoulder,  where  the  line  of  fracture  follows  either  the  anatomical 
or  the  surgical  neck,  and  the  special  difficulty  in  treatment  arises  from 
the  smalhiess  of  the  upper  fragment,  whereby  it  is  made  difficult  or 
impossible  so  t^  act  upon  it  as  to  return  it  to  its  normal  position  in 
the  joint.  In  68  cases  of  this  kind  collected  by  Thamhayn^  14  were 
of  the  anatomical  neck  of  the  humerus,  and  of  these  in  only  2  was 
the  dislocation  reduced;  while  of  the  46  cases  in  which  the  fracture 
occupied  the  surgical  neck  20  were  reduced.  ]McBurney's  method 
of  reducing  with  the  aid  of  a  hook  inserted  into  the  fragment 
greatly  diminished  the  difficulty.  The  mechanism  of  the  combined 
lesions  is  sometimes  obscure,  as  regards  its  details,  and  varies  in  the 
different  cases,  the  dislocation  sometimes  preceding  and  sometimes  fol- 
lowing the  fracture,  and  perhaps  sometimes  occurring  simultaneously, 
In  a  specimen  figured  by  Kr5nlein  the  head  of  the  humerus,  after 
fracture  of  the  anatomical  neck,  has  been  completely  reversed  and  lies 
wedged  between  the  tuberosities. 

Bloodvessels.  Injury  of  a  large  bloodvessel  adjoining  a  dislocated 
joint  (the  dislocation  not  being  compound)  is  a  comparatively  rare  acci- 
dent, and  one  that  depends  either  upon  the  close  relations  of  the  vessels 

1  Birkett :  Medlco-Chirurgical  Transactions,  1869,  vol.  lii.  p.  133.  Moxon  :  Medical 
Times  and  Gazette,  1872,  vol.  i.  p.  96. 

'  Riedel  :  Beilage  zum  Centralb.  fiir  Chir.,  1885,  p.  92. 
'  Thamhayn  :  Schmidt's  Jahrbuch,  1868,  vol.  cxl. 


COMPLICATIONS  OF  RECENT  DISLOCATIONS.  496 

and  the  bones,  as  at  the  shoulder  and  knee,  or  upon  violence  so  great 
as  to  displace  the  bone  to  a  greater  distance  than  usual,  or  in  an 
unwonted  direction. 

In  most  of  the  recorded  cases  the  dislocation  has  been  of  the  shoul- 
der, inward  and  forward,  and  the  lesion  has  consisted  either  in  the 
rupture  of  a  large  arterial  branch,  the  anterior  circumflex  or  the  sub- 
scapular, at  or  near  its  origin,  or  in  such  stretching  of  the  axillary 
artery  that  its  inner  and  middle  coats  have  been  torn  across,  the  outer 
one  remaining  undivided,  or,  more  rarely,  in  rupture  of  the  main  vein. 
The  injury  may  result  in  the  immediate  formation  of  a  traumatic  aneu- 
rism or  in  the  gradual  formation  of  an  encysted  one,  or  in  gangrene  of 
the  distal  portion  of  the  limb.  In  some  of  the  recorded  cases  it  is  not 
possible  to  determine  whether  the  injury  to  the  vessel  was  the  imme- 
diate result  of  the  dislocation  or  of  the  efforts  to  reduce  it. 

The  symptoms  vary  greatly,  but,  except  at  the  shoulder,  are  not 
likely  to  leave  any  doubt  concerning  the  nature  and  details  of  the 
injury.  Injury  to  the  inner  and  middle  coats  alone  may  in  some  cases 
be  recognized  by  the  immediate  cessation  of  the  brachial  and  radial 
pulse,  in  others  only  by  the  subsequent  gradual  formation  of  an  aneu- 
rism. In  other  cases  the  prompt  appearance  and  rapid  growth  of  a 
fluctuating  swelling  in  the  axilla,  perhaps  accompanied  by  extensive 
ecchymosis  and  alarming  symptoms  of  collapse  or  shock,  sufficiently 
prove  the  fact  of  an  internal  hemorrhage ;  but  the  source  of  the  bleed- 
ing, whether  from  an  arterial  branch,  the  main  artery,  or  the  vein,  may 
remain  in  doubt,  for  the  radial  pulse  may  persist  even  when  the  hem- 
orrhage comes  directly  from  the  axillary  artery.  The  subject  will  be 
more  fully  discussed  in  Chapter  XXXIV. 

In  a  case  observed  by  Korte,'  this  complication  accompanied  a  dis- 
location of  the  shoulder  caused  by  a  blow  received  upon  its  upper  sur- 
face while  the  arm  was  abducted  ;  the  dislocation  was  spontaneously 
reduced  before  the  arrival  of  the  surgeon,  and  probably  the  displace- 
ment was  only  slight.  An  aneurism  formed,  and  was  opened  under  the 
impression  that  it  was  an  enlarged  lymphatic  gland.  The  autopsy  indi- 
cated that  the  lesion  was  avulsion  of  the  anterior  circumflex  artery  at 
its  origin,  and  showed  also  that  the  inner  and  middle  coats  of  the 
axillary  artery  were  torn  transversely  at  a  higher  point,  but  the  calibre 
of  the  vessel  was  not  thereby  obstructed. 

The  following  cases  illustrate  other  varieties  : 

Mr.  J.  W.  Turner^  reported  two  cases  of  rupture  of  the  popliteal 
artery  complicating  dislocation  of  the  knee.  In  the  first  a  man,  twenty- 
four  years  old,  fell  from  a  height  of  thirty  feet  and  sustained  a  com- 
pound dislocation  of  the  knee,  the  condyles  of  the  femur  projecting 
through  the  integument  of  the  ham.  The  limb  was  immediately  ampu- 
tated, and  the  two  inner  coats  of  the  popliteal  artery  were  found  to  be 
ruptured,  the  outer  coat  remaining  untorn. 

In  the  second  case  a  middle-aged  woman  fell  while  carrying  a  heavy 
burden  on  her  back.  There  was  found  a  dislocation  of  the  knee  to- 
gether with  a  wound  in  the  ham,  through  which,  it  was  said,  the  con- 

^  Korte :  Archiv  fiir  klinische  Chirurgie,  1882,  p.  636. 

"  Turner:  Transactions  of  the  Edinburgh  Mcdico-Chirurgical  Society,  vol.  iii.  p.  308. 


496  DISLOCATIONS. 

flvles  of  the  femur  had  projected.  There  was  no  bleeding ;  the  limb 
became  greatly  swollen,  and  the  patient  died  on  the  tenth  day.  The 
artery  and  vein  were  found  to  have  been  torn  completely  across. 

Dr.  M.  Goldsmith  ^  reported  the  case  of  a  man,  forty  years  old,  who 
suffered  a  dislocation  of  the  left  femur ;  "  the  head  of  the  bone  being 
thrust  under  Poupart's  ligament  overrode  the  margin  of  the  pelvis  in 
such  a  manner  as  to  underlie  the  femoral  artery  ;  it  remained  unreduced 
for  two  months,  when  he  came  under  observation  with  a  diffused  swell- 
ing occupying  the  groin,  filling  the  iliac  fossa,  and  extending  to  the 
middle  of  the  thigli ;  feeble  pulsation  ;  tumor  appeared  a  few  days  after 
the  accident ;  pain  severe ;  diagnosis,  aneurism  ;  treatment,  ligature  of 
the  common  iliac  artery  ;  death  on  fifth  day."  The  femoral  and  exter- 
nal iliac  arteries  were  perforated  to  the  extent  of  an  inch  on  the  pos- 
tero-external  aspect ;  the  head  of  the  femur  lay  in  the  cavity  of  the 
aneurism. 

Cases  also  have  been  reported  of  rupture  of  the  anterior  and  poste- 
rior tibial  arteries  in  dislocation  of  the  ankle ;  and  S^dillot^  published 
one  in  which  the  brachial  artery  was  ruptured  at  the  elbow  by  being 
stretched  over  the  end  of  the  humerus  in  a  dislocation  of  the  radius 
and  ulna  backward.  Sherrill  {Annals  Surg.,  Oct.,  1913,  p.  534)  reported 
another. 

Nerves.  Injuries  of  the  nerves  may  be  demonstrated  by  direct  exami- 
nation or  inferred  from  the  symptoms.  Examples  of  the  former  are 
uncommon,  and  in  some  of  the  latter  it  may  remain  in  doubt  whether 
the  nerves  were  injured  by  the  displacement  of  the  bone,  or  by  the 
efforts  to  reduce  the  dislocation,  or  by  the  independent  action  of  the 
violence  upon  them.  It  is  asserted^  that  a  fall  upon  the  hand  or 
shoulder,  without  lesion  of  the  skeleton,  is  competent  to  cause  palsy  of 
the  arm  ;  hence,  it  is  not  always  to  be  inferred  that  a  palsy  following 
a  dislocation  has  been  caused  by  the  pressure  of  the  head  of  the  bone 
upon  the  nerves,  and  this  is  especially  true  of  those  cases  in  which  a 
blow  has  been  received  directly  upon  the  shoulder,  and  the  deltoid 
alone  is  paralyzed. 

The  injury  may  be  a  complete  rupture  or  laceration  of  one  or  more 
nerve  trunks,  or  a  contusion  with  extravasation  of  blood  about  the  nerve 
and  amid  its  fibres,  or  a  neuritis  originating  in  an  injury  of  some  lesser 
nerve  and  extending  thence  to  the  main  trunk,  or  an  inflammatory  pro- 
cess extending  to  the  nerve  and  causing  its  compression  by  newly 
formed  connective  tissue,  or  simple  compression  by  the  displaced  bone. 

Rupture  or  laceration  of  the  nerve  is  caused  by  violent  pressure 

against  it  of  the  displaced  end  of  the  bone,  and,  in  the  case  at  least  of 

the  larger  trunks,  it  appears  commonly  to  be  associated  with  extensive 

laceration  of  the  other  soft  parts,  including  even  the  overlying  skin. 

Contusion  of  the  nerve  may  be  produced  in  the  same  manner,  and  then 

represents  a  less  degree  of  the  same  injury,  or  by  compression  of  the 

nerve  between  the  displaced  bone  and  an  adjoining  portion  of  the 

skeleton,  as  between  the  head  of  the  humerus  and  the  wall  of  the 

thorax. 

1  Goldsmith:  American  Journal  of  the  Medical  Sciences,  July,  1860,  p.  30;  abstract 
from  the  Louisville  Medical  Journal,  February,  1860. 
'  Sedillot:  Diet.  Encyclopedique,  art.  Luxations,  p.  261. 
'  Weir  Mitchell :  Injuries  of  Nerves,  p.  99. 


COMPLICATIONS  OF  RECENT  DISLOCATIONS.  497 

The  symptoms  vary  with  the  character  of  the  injury  ;  laceration  is 
immediately  followed  by  motor  paralysis  and  loss  of  sensation  in  the 
region  supplied  by  the  nerve,  which  are  ])ermanent  or  persist  until  the 
integrity  of  the  nerve  is  restored ;  in  other  forms  of  injury  there  are 
varying  degrees  of  paralysis  and  loss  of  sensation,  numl)ness,  pain, 
alteration  of  local  nutrition,  and  other  symptoms  of  neuritis,  limited 
at  first  to  the  nerve  directly  injured,  and  afterward  perhaps  extending 
to  others.  In  many  of  the  recorded  cases  a  cure  has  followed  the 
systematic  use  of  electricity. 

The  statistics  of  the  Friedrich's  Hospital  collected  by  Holm^  show 
that  of  112  cases  of  dislocation  of  the  shoulder  there  was  general  paral- 
ysis of  the  arm  in  7,  and  paralysis  of  the  deltoid  alone  in  10.  In  one 
of  them  all  the  muscles  supplied  by  the  median  nerve  were  paralyzed, 
while  those  supplied  by  the  musculo-spiral  were  unaffected.  This  is  a 
very  much  larger  proportion  than  I  have  observed. 

The  recorded  cases  of  rupture  of  a  nerve  verified  by  direct  exami- 
nation are  few  ;  the  following  are  examples  of  different  forms  : 

Hilton^  examined  the  body  of  a  man  who  died  thirteen  weeks  after 
having  received  a  dislocation  of  the  shoulder  into  the  axilla ;  the  del- 
toid M'as  much  atrophied,  the  circumflex  nerve  was  small  and  was 
"distinctly  lacerated,  but  its  actual  condition  was  changed  by  some 
strong  cellular  adhesions,  fixing  it  with  the  radio-spiral  nerve  and  the 
axillary  artery  to  the  inner  surface  of  the  subscapularis  muscle." 
Bouley^  presented  to  the  Societe  Anatomiqne  a  specimen  of  complete 
dislocation  outward  of  both  bones  of  the  forearm  at  the  elbow,  with 
fracture  of  the  outer  condyle  of  the  humerus,  caused  by  a  fall  upon 
the  elbow  from  a  height  of  twenty-four  feet.  The  patient  refused 
amputation  and  died  twenty  days  after  the  receipt  of  the  injury. 
"The  lateral  ligaments  of  the  elbow  were  entirely  ruptured,  both 
bones  of  the  forearm  were  situated  external  to  the  lower  end  of  the 
humerus,  and  the  ulnar  nerve  was  lacerated  at  the  level  of  the  articular 
surface." 

Holl  *  found  in  the  dissecting-room  a  cadaver  with  a  marked  deformity 
of  the  elbow,  and  on  examination  it  appeared  that  the  individual  had 
suffered  fracture  of  the  upper  end  of  the  ulna  and  dislocation  of  the 
head  of  the  radius  upward  and  inward,  and  that  the  ulna  artery  and 
ulnar  and  median  nerves  had  been  completely  divided  and  had  not 
reunited.  In  9  reported  cases  of  the  same  combination  of  fracture  and 
dislocation  the  musculo-spiral  nerve  has  been  injured.  See  Chapter 
XLVI. 

Miiller,^  seven  mouths  after  dislocation  of  the  shoulder  which  had 
been  easily  reduced  and  which  had  been  followed  by  gradual  paralysis 
of  motion  and  sensation  in  the  arm,  found,  by  an  axillary  incision,  the 
artery  and  main  nerves  tightly  compressed  by  a  cicatricial  band  about 
a  quarter  of  an  inch  wide.      On  division  of  the  band  pulsation  at  once 

1  Holm :  Schmidt's  Jahrbuch,  vol.  cxxi.  p.  82. 

2  Hilton :  Guy's  Hospital  Reports,  1847,  vol.  v.  p.  9f!. 

3  Bouley :  Bull,  de  la  Soc.  Anatomique,  1837,  p.  101. 
■*  Holl :  Medicin.  Jahrbuch,  Wien,  1880,  p.  151. 
sMiiUer :  Centralb.  fiir  Chir.,  1892,  p.  611. 


498  DISLOCATIONS. 

reappeared  in  the  brachial  and  radial  arteries ;  sensation  and  muscular 
function  reappeared  gradually. 

Of  the  cases  that  have  been  observed  clinically  the  injury  in  most 
has  been  attributed  to  the  reduction,  as  a  consequence  of  too  forcible 
traction,  extreme  abduction  of  the  limb  (arm),  or  to  the  presence  of 
adhesions  between  the  nerve  and  the  parts  with  which  it  has  been  tem- 
porarily brought  into  contact.  In  some  of  these  cases  the  correctness 
of  this  view  cannot  be  questioned  ;  in  others  the  necessary  data  for  an 
opinion  are  lacking. 

A  raan^  fifty-four  years  old  was  seized  by  the  right  arm  and  shaken 
so  violently  as  to  dislocate  the  humerus  into  the  axilla,  causing  pain  in 
the  shoulder  and  instant  loss  of  feeling  and  motion  in  the  hand. 
Reduction  on  the  third  day.  "  Six  weeks  afterward  the  whole  hand 
and  lower  side  of  the  forearm  were  oedematous,  and  the  former  also 
hard  and  brawn-like,  resisting  pressure.  The  fingers  were  in  the  same 
state,  and  the  whole  hand  was  dark  and  congested,  but  not  shiny  or 
smooth.  The  joints  from  the  wrist  to  the  finger  ends  were  sore,  swol- 
len, and  very  stiflF.  The  whole  palm  was  the  seat  of  pretty  severe 
burning,  with  no  darting  or  other  pain."  Partial  loss  of  touch  and 
pain-sense  in  the  median  and  radial  distribution.  The  elbow  motions 
were  perfect,  wrist  flexion  good,  extension  lost ;  flexion  of  the  fingers 
good,  extension  and  lateral  motions  lost  from  palsy  of  the  extensors 
and  interossei. 

A  soldier  ^  fell  from  a  tree,  striking  upon  and  dislocating  his  left 
shoulder ;  the  dislocation  was  reduced  within  twenty-four  hours,  and, 
the  previous  pain  and  numbness  disappearing,  he  remained  well  for 
four  weeks,  when  the  arm  began  to  waste,  with  loss  of  power  which 
became  complete  in  a  few  months.  Sensation  was  much  less  altered. 
At  the  close  of  a  year  there  was  only  partial  ability  to  flex  the  arm, 
and  slight  use  of  the  flexors  and  extensors  of  the  fingers.  Marked 
atrophy ;  contraction  of  the  pronators.  Rapid  relief  and  final  cure 
were  obtained  by  electricity. 

A  man  '■'  twenty-five  years  old  was  admitted  to  the  Hotel-Dieu  with 
an  intracoracoid  dislocation  of  the  left  shoulder,  caused  shortly  before 
by  a  fall.  Any  motion  communicated  to  the  limb  caused  great  pain 
and  violent  involuntary  contraction  of  all  its  muscles.  The  next  morn- 
ing the  dislocation  was  found  to  have  become  subglenoid,  the  limb  was 
completely  paralyzed,  but  without  loss  of  sensation,  and  although  com- 
municated motion  was  still  painful,  it  did  not  cause  reflex  contractions 
of  the  muscles.  Reduction  was  readily  effected  with  the  aid  of  anaes- 
thesia. The  muscles  of  the  shoulder  reacted  to  the  faradic  current; 
those  of  the  arm  and  forearm  did  not.  The  limb  wasted  rapidly  ; 
under  electrical  treatment  an  almost  complete  cure  was  obtained  in 
about  two  years. 

Kronlein  "*  quotes  Hutchinson  as  having  seen  paralysis  of  the  sciatic 
nerve  follow  an  ischiatic  dislocation  of  the  femur ;  and  Sir  Astley 
Cooper  ^  quotes  a  case  in  which  numbness  of  the  limb  accompanied  the 

'Weir  Mitchell:  Injuries  of  Nerves,  p.  103.        ■^Weir  Mitchell:  Loc.  cit.,  p.  101. 

3  Duchenne :  De  I'Electrisation  localisge,  2d  ed.,  p.  179. 

<  Kronlein :  Loc.  cit.,  p.  34.  °  Cooper  :  Loc.  cit.,  p.  67. 


COMPLICATIONS  OF   RECENT  DISLOCATIONS.  499 

same  injury.  Cooper^  also  quotes  a  case  of  suprapubic  disloeatiou  iu 
which  the  pressure  of  the  head  of  the  femur  upon  the  anterior  crural 
nerve  caused  numbness  of  the  thioli. 

Viscera.  Excluding  the  common  implication  of  the  spinal  cord  in 
dislocations  of  the  vertebrte,  there  are  few  recorded  cases  of  injury  to 
parts  lying  within  the  body  or  neck  by  dislocated  bones.  Such  injuries 
must,  to  a  greater  or  less  extent,  accompany  dislocation  of  the  head  of 
the  femur  through  the  floor  of  the  acetaljulum  into  the  pelvis,  and 
complete  dislocation  backward  of  the  sternal  end  of  the  clavicle  has 
in  some  cases  been  accompanied  by  symptoms  indicating  pressure  on 
the  trachea  or  oesophagus. 

A  case  that  is  entirely  unique,  and  interesting  not  only  because  of 
the  distance  to  which  the  bone  was  displaced,  but  also  because  of  the 
changes  subsequently  undergone  by  the  bone,  and  of  the  ease  with 
which  the  deformity  was  borne,  is  reported  by  Prochaska^  and  by 
Larrey,^  who  had  examined  the  specimen.  A  lad,  sixteen  or  seven- 
teen years  old,  dislocated  his  right  humerus  by  a  fall  upon  the  abducted 
elbow,  and  the  head  of  the  bone  was  driven  between  the  second  and 
third  ribs  (Prochaska  says  the  third  rib  was  fractured)  into  the  chest, 
stripping  up  the  pleura,  but  not  perforating  it.  All  attempts  to  reduce 
it  were  unavailing,  and  the  subsequent  treatment  was  limited  to  vene- 
section, warm  baths,  and  antiphlogistic  measures  for  the  relief  of  urgent 
symptoms.  The  patient  survived  until  the  age  of  thirty-one  (forty, 
Prochaska),  and,  although  the  arm  remained  abducted,  gained  his  live- 
lihood by  woodchopping.  At  the  autopsy  the  head  of  the  humerus 
was  found  within  the  thorax,  covered  by  the  pleura,  and  its  neck  firmly 
placed  between  the  second  and  third  ribs.  The  head  was  so  soft  that 
it  yielded  to  the  slightest  pressure  of  the  finger  ;  the  articular  cartilage 
and  bony  texture  of  all  the  portion  that  lay  within  the  chest  had 
entirely  disappeared,  leaving  only  a  few  membranous  remains  of  the 
humerus;  of  which  the  greater  part  seemed  to  belong  to  the  costal 
pleura.  Prochaska  describes  it  as  "  naked,  soft,  yielding  to  the  softest 
pressure,  presenting  only  a  thin  envelope,  and  almost  empty  within, 
since  it  had  lost  more  than  half  of  its  internal  bony  substance." 

Soft  Parts  and  Integument  (Compound  Dislocations).  Although 
instances  of  this  complication  have  been  recorded  for  almost  every 
joint,  they  are  yet  of  rare  occurrence,  and  mainly  restricted  to  the 
elbow,  knee,  ankle,  and  phalanges.  Except  in  the  latter  case,  they 
are  commonly  the  result  of  extreme  violence,  and  the  wound  of  the 
skin  is  produced  either  by  the  direct  action  of  this  violence,  or  from 
within  outward  by  the  ]irojecting  end  of  the  bono. 

The  complication  in  the  case  of  the  larger  joints  is  very  grave, 
because  of  the  extent  of  the  injury,  which  is  usually  great  and  marked 
by  much  laceration  and  bruising  of  the  tissues,  and  also  because  of  the 
special  dangers  due  to  the  prolwble  infection  of  the  wound. 

The  treatment  may  require,  in  addition  to  the  most  rigorous  anti- 
septic measures,  the  partial  excision  of  the  joint,  because  of  the  (h'fii- 

1  Cooper :  Loc.  cit.,  p.  74. 

2  Prochaska  :  Disquisite  Anatomico-ijhysiol.  Org.  Humani.  Wicn,  1812,  quoted  by 
Malgaigne. 

•^Larrey :  Mem.  de  Chir.  Militaire,  vol.  ii.  pp.  405-407. 


500  DISLOCATIONS 

cultv  of  otherwise  providing  efficient  drainage  of  all  the  recesses  and 
pouches  of  the  synovial  sac. 

Compound  dislocations  of  the  shoulder  and  hip  are  rare,  those  of  the 
elbow  and  knee  less  so,  and  those  of  the  smaller  joints  much  more 
frequent. 

REPAIR. 

Only  a  few  observations  have  been  made  of  reduced  dislocations 
undergoing,  or  that  have  undergone,  repair.  Clinically  it  is  known 
that  after  a  period  of  a  few  days  or  weeks  marked  by  gradually 
diminishing  tenderness  and  swelling,  the  joint  can  be  freely  used  with- 
out pain,  but  that  sometimes  the  range  of  motion  remains  limited  for 
a  much  longer  period,  and  that  in  some  cases  there  is  a  marked  ten- 
dency to  recurrence  of  the  dislocation.  In  a  few  cases,  in  which 
patients  have  died  within  a  few  days  after  having  suffered  a  disloca- 
tion, the  surrounding  tissues  have  shown  the  remains  of  the  extrava- 
sation of  blood  that  had  taken  place  amid  them,  and  the  rent  in  the 
capsule  has  either  been  occupied  by  a  clot  or  has  been  empty  and 
without  evidence  of  repair.  It  is  to  be  presumed,  however,  that  repair 
usually  takes  place  after  dislocation,  as  after  other  subcutaneous  injuries, 
without  suppuration  or  even  much  inflammatory  reaction,  that  the 
ruptured  capsule  reunites  or  that  the  gap  in  it  is  filled  by  condensation 
and  adhesion  of  the  adjoining  connective  tissue,  that  the  lacerated 
muscles  and  ligaments  are  repaired  in  like  manner,  and  that  these 
cicatrices  pursue  the  evolution  common  to  their  class. 

This  process  may,  however,  be  disturbed  by  various  complications. 
If  the  injury  has  been  exceptionally  severe,  if  the  bone  has  been  widely 
displaced,  and  the  surrounding  tissues  much  lacerated,  if  the  efforts  to 
reduce  have  been  violent  and  long  continued,  if  the  joint  has  not  been 
properly  immobilized,  if  passive  motion  has  been  injudiciously  begun 
and  maintained,  or,  finally,  if  the  general  condition  of  the  patient  is 
unfavorable  for  repair,  the  inflammatory  reaction  may  become  exces- 
sive, and  even  end  in  suppuration  and  pysemia.  If  it  stops  short  of 
this  disastrous  result,  it  may  yet  lead  to  partial  or  complete  anchylosis 
through  the  formation  of  adhesions  between  the  opposed  articular  sur- 
faces or  the  thickening  and  retraction  of  the  capsule  and  peri-articular 
tissues.  The  older  records  contain  numerous  instances  in  which  sup- 
puration appears  to  have  been  caused  by  the  efforts  to  reduce,  but  this 
accident  has  become  much  less  common  since  the  introduction  of  anaes- 
thesia and  the  substitution  of  the  so-called  "mild  "  methods  by  manip- 
ulation for  the  forcible  traction  by  pulleys  which  was  formerly  so  much 
in  vogue. 

Fractures  of  apophyses,  or  portions  of  bone  to  which  muscles  or  liga- 
ments are  attached,  are  rej^aired  either  bv  bonv  callus  or  by  a  fibrous 
band,  the  difference  depending  on  the  extent  of  the  separation  and  the 
independent  motion  of  the  fragment.  The  fragment  may  be  withdrawn 
to  such  a  distance  that  the  attached  muscle  or  muscles  permanently 
cease  to  exercise  any  control  over  the  main  bone,  which,  in  conse- 
quence, is  exposed  to  frequent  anrl  easy  recurrence  of  the  dislocation. 

The  same  infirmity  may  residt  from  defective  repair  of  fracture  of 


REPAIR   OF  RECENT  DISLOCATIOyS. 


501 


Fig.  359. 


the  rim  of  an  orbicular  cavity.  Instances  of  the  former  variety  are  most 
common  at  the  shoulder-joint,  those  of  the  latter  are  found  at  the  hip  and 
shoulder.  Another  cause  of  the  liability  to  recurrence  at  the  shoulder — 
laxity  of  the  capsule — has  been  indicated  by  Jossel,i  who  had  the  oppor- 
tunity to  examine  four  such  cases  after  death,  and  also  five  other  shoulder- 
joints  showing  similar  conditions  found  in  a  series  of  about  two  hundred 
cadavers  examined  in  the  dissecting-room  at  Strassburg ;  he  found 
in  all  that  the  supraspinatus  and  infraspinatus  muscles  had  been  torn 
loose  from  their  attachment  to  the  greater  tuberosit},  had  retracted 
behind  the  acromion,  and  had  un- 
dei'gone  atrophy  and  fatty  degenera- 
tion. The  relations  of  the  tendons 
of  these  muscles  with  tiie  articular 
capsule  are  so  close  that  the  rupture 
of  the  former  involves  also  that  of 
the  latter,  and  the  retraction  of  the 
former  creates,  by  drawing  back  one 
side  of  the  rent,  a  large  gap  in  the 
upper  part  of  the  capsule  opening 
into  the  subacromial  bursa.  In  the 
process  of  cicatrization  the  front  part 
of  the  capsule,  that  lying  between 
its  attachment  to  the  humerus  and 
the  rent,  becomes  adherent  at  the 
edge  of  the  rent  to  the  under  sur- 
face of  the  deltoid  close  by  its  at- 
tachment to  the  acromion,  while  the 
posterior  li])  of  the  rent,  after  retrac- 
tion with  the  tendon,  becomes  per- 
manently fixed  at  the  posterior  part 
of  the  acromion.  The  under  surface 
of  the  acromion  is  thus  left  to  fill 
the  gap  between  the  two  lips,  to 
form  the  upper  limit  of  the  articular  cavity,  and  to  be  in  direct  con- 
tact with  the  head  of  the  humerus.  In  none  of  Jossel'.s  four  cases 
was  the  normal  communication  between  the  cavity  of  the  joint  and 
the  subscapular  bursa  found  to  be  enlarged  ;  in  one  the  subcoracoid 
l)ursa  communicated  with  the  joint,  and  in  one  the  tendon  of  tlu; 
longhead  of  the  biceps  was  ruptured,  and  its  torn  end  had  becumc 
fixed  in  the  bicipital  groove.  In  two  of  the  cases  a  small  defect  with 
smooth  edges  was  found  in  the  capsule  below  the  tendon  of  the  sub- 
scapularis,  and  in  the  others  the  capsule  appeared  thinned  at  the  same 
point.  Apparently  this  indicated  the  place  at  which  the  head  of  the 
humerus  escaped  through  the  capsule  at  the  time  of  the  first  dislo- 
cati(jn. 

The  cavity  of  the  joint  was  greatly  enlarged  l>y  the  changes  in  tiie 
capsule;  in  the  first  its  capacity  was  90  cubic  centimetres,  as  against 
28  in  a  normal  joint,  and  its  length  along  the  upper  portion  was  10 
centimetres  instead  of  the  normal  o^. 

1  Jossel:  Deutsche  Zeitschrift  fur  Chiriirgie,  18S(),  vol.  xiii.  p.  I(i7. 


Recurrent  or  habitual  dislocation  of  the 
shoulder,  showing  the  opening  into  the  sub- 
acromial bursa.    (JbssEL.) 


502  DISLOCATIONS. 

This  condition  of  the  capsule,  aided  by  the  withdrawal  of  the  con- 
trol and  support  normally  supplied  by  the  supraspinatus  and  infra- 
spinatus, muscles,  seems  entirely  adequate  to  explain  the  easy  recur- 
rence of  the  dislocation,  and  the  recent  cases  of  relief  by  operative 
shortening  of  the  anterior  portion  of  the  capsule  are  corroborative  of 
the  opinion. 

Gangrene  of  the  limb  may  ensue  upon  the  rupture  of  the  principal 
vessels,  or  even  upon  extensive  laceration  and  violent  inflammatory 
reaction  ;  and  paralysis  of  one  or  several  muscles  may  manifest  itself 
immediately  or  only  after  the  limb  is  again  brought  into  use,  the  result 
of  injury  to  nerve  trunks  or  of  contusion  of  the  muscle  itself,  or  of 
compression  of  the  nerve  by  a  cicatricial  band  as  in  Miiller's  case 
quoted  above,  p.  497. 


CHAPTER  XXX. 

THE  PATHOLOGY  OF  UNREDUCED  ("ANCIENT,"  "  INVETERATE") 

DISLOCATIONS. 

The  changes  that  take  place  about  joints  that  have  long  remained 
dislocated  are  well  understood,  through  direct  observations  of  many 
specimens  in  man  and  through  experiment  upon  animals.  These 
changes  are  partly  the  direct  result  of  purely  inflammatory  processes 
excited  by  the  traumatism  and  the  changed  relations  of  the  parts, 
partly  that  of  disease,  and  partly  tiiat  of  a  seeming  effort  of  nature  to 
create  a  new  and  serviceable  joint.  The  changes  consist,  in  general 
terms,  in  the  condensation  and  thickening  of  connective  tissue  about 
the  displaced  bone  in  such  a  manner  as  to  protect  it  against  further 
displacement,  and  in  the  change  of  the  bones  at  the  new  points  of  con- 
tact partly  by  absorption  and  partly  by  the  formation  of  new  bony 
outgrowths  through  continued  slight  irritation  of  the  bone  itself,  the 
periosteum,  and  the  adjoining  fibrous  and  ligamental  tissues.  The 
irritation  which  leads  to  these  changes  is  furnished  by  motion,  use,  of 
the  limbs ;  the  most  striking  examples  are  found  at  the  shoulder  and 
the  hip,  and  these  will  be  used  as  the  basis  of  the  following  description. 

The  first  changes,  in  point  of  time,  are  those  in  the  bruised  and  torn 
soft  parts  amid  which  the  end  of  the  bone  has  lodged  after  its  escape 
through  the  rent  in  the  capsule.  The  loose  connective  tissue  lying 
about  the  vessels,  nerves,  and  muscular  bundles,  bruised  and  pressed 
back  by  the  head  of  the  bone  and  infiltrated  Avith  extravasated  blood, 
reacts  in  the  usual  manner  under  the  traumatism  by  becoming  the  seat 
of  an  exudation  and  by  multiplication  of  its  cellular  elements.  The 
latter  follow  their  natural  evolution  into  fibrous  tissue,  and  thus  is 
formed  about  the  bone  a  continuous  fibrous  envelope  enclosing  a  cavity 
within  which  the  end  of  the  bone  lies,  more  or  less  free,  and  continuous 
structurally  on  its  outside  with  the  adjoining  tissues,  some  of  which — 
vessels,  nerves,  and  muscular  fibres — may  be  firmly  imbedded  in  it. 
Its  inner  surface  is  smooth  and  lined  with  flat  cells  resembling  those 
found  on  the  surface  of  normal  or  accidental  bursae,  and  it  is  moistened 
by  a  small  amount  of  liquid  which,  in  some  cases,  closely  resembles 
synovia.  It  seems  probable  that  when  real  synovia  is  present  it  is 
furnished  by  portions  of  the  original  capsule  which  have  remained 
adherent  to  the  bone  and  have  formed  part  of  the  new  cavity.  Indeed, 
the  new  cavity  is  usually  only  an  enlargement  of,  or  addition  to,  the 
original  one,  its  connection  with,  or  its  entire  independence  of,  the  old 
one  being  determined  by  the  character  and  extent  of  the  rent  in  the 
capsule  and  the  distance  to  which  the  head  of  the  bone  has  passed 
through  it ;  but  the  capsule  may  be  torn  away  from  the  humerus,  for 
example,  so  completely  that  it  falls  together  behind  it  and  its  cavity  is 

(  503  ) 


504 


DISLOCATIONS. 


obliterated  by  adhesion  of  the  opposing  surfaces  or  is  shut  oif  by  union 
of  the  torn  edges.  The  new  capsule  is  so  small  and  close  and  the 
bands  formed  between  the  bones  by  the  condensation  and  increase  of 
the  surrounding  tissues  are  so  firm  that  motion  is  greatly  restricted  or 
wholly  lost,  and  restoration  of  the  original  relations  can  be  eifected  only 
after  a  division  or  laceration  of  those  tissues  far  more  extensive  than 
that  which  accompanied  the  dislocation. 

But  while  these  changes  in  the  soft  parts  tend  permanently  to  fix  the 
bone  in  its  new  position,  other  changes  take  place  in  the  periosteum 
and  the  bone  itself  upon  which  the  displaced  articular  end  rests  and 
moves,  which,  on  the  other   hand,  tend  to  make  this  new  position  a 


Fig.  360. 


Fig.  361. 


Old  supracotyloid  dislocation  of  the  femur,  with 
very  complete  new  acetabulum.  From  the  collec- 
tion at  Bonn.    (Kronlein.) 


Scapula  showing  new  socket  found  in 
an  old  unreduced  subcoracoid  disloca 

tion.    (Cooper.) 


more  suitable  resting-place  and  to  give  it  a  form  and  character  like 
those  of  the  part  it  is  to  replace.  Thus,  a  new  cotyloid  cavity  may  be 
formed  upon  the  ilium,  or  a  new  glenoid  cavity  on  the  inner  side  of 
the  scapula  adjoining  the  old  one.  In  this  new  formation  of  bone  two 
processes  may  take  part — production  of  bone  by  the  periosteum,  and 
ossification  of  the  old  ligaments  and  new  fibrous  tissue.  The  perios- 
teum may  produce  bone  either  after  it  has  been  stripped  up  or  while  it 
is  still  in  place.  If,  in  the  dislocation  of  the  liead  of  the  bone,  a  por- 
tion of  the  rim  of  the  corresponding  articular  cavity  is  broken  off  and 
pushed  away,  carrying  with  it  a  strip  of  periosteum  torn  from  the 
adjoining  surface,  but  preserving  its  connection  with  both  ]iieces,  or  if 
the  periosteum  is  stripped  up  by  the  attached  capsule  or  a  ligament,  as 


PATHOLOGY  OF   UNREDUCED  DISLOCATIONS. 


505 


occurs  so  frequently  at  the  elbow,  this  loosened  strip  forms  on  its  side 
the  limit  of  the  new  cavity,  and  produces  on  its  under  surface  new 
bone  which  is  continuous  with  the  old  and  with  the  frag^ment  of  the 
rim,  if  such  has  been  broken  oflr,  constituting  a  bridge  between  them. 

If  the  periosteum  is  not  stripped  up,  but  the  head  of  the  bone  escapes 
entirely  from  the  cavity  and  comes  to  rest  upon  the  outside  of  a  layer 
of  periosteum  still  adherent  to  its  bone,  this  periosteum,  irritated  by 
the  pressure  and  movements,  produces  new  bone  between  itself  and  the 
old,  and  this  production  is  greatest  in  the  zone  just  around  the  })oint  of 
greatest  pressure.  The  portion  of  periosteum  directly  pressed  upon  dis- 
appears under  tiie  pressure,  leaving  a  bare  surface  of  bone  in  contact 
witii  the  displaced  head,  or  becomes  fibrous  or  hbro-cartilaginous  in 
structure ;  while  in  the  immediately  adjoining  portion  the  osteogenetic 
property  is  called  into  play  and  a  ridge  of  bone  is  built  up  around  the 

Fig.  362. 


Backward  dislocation  of  elbow.    Bony  fusion  between  ulna  and  humerus. 

central  denuded  area.  This  may  be  a  sharply  defined  rim  rising  to  a 
considerable  height  and  closely  resembling  that  for  which  it  is  a  sub- 
stitute, or  it  may  be  a  mass  of  irregular  height  and  outline,  having  little 
or  no  resemblance  to  either  the  glenoid  or  cotyloid  cavity. 

The  details  of  this  formation,  as  observed  by  Baiardi  ^  at  the  hip  in 
animals,  consist,  first,  in  the  appearance  of  a  circular  cartilaginous  wall 
whose  free  border  is  continuous  with  the  new-formed  fibrous  capsule, 
its  base  resting  upon  the  ilium  and  its  inner  surface  in  contact  with  the 
head  of  the  femur ;  its  ossification  (in  rabbits)  is  complete  by  the  thir- 
tieth (lav,  except  along  its  concave  surface,  where  it  remains  soft, 
shading  off  toward  the  centre  of  the  new  acetal)ulum  into  a  whitish, 
cartilaginous  like  tissue,  which  takes  the  j)iace  of  the  destroyed  perios- 
teum. On  its  free  border  it  has  the  structure  of  fibro-cartilage  ;  on  the 
concave  surface  it  closely  approximates  that  of  hyaline  articular  car- 
1  Baiardi :  Arch,  per  le  Scieuze  mediche,  1880,  vol.  iv.,  quoted  by  Kronlein. 
36 


506 


DISLOCATIONS. 


tilage.  At  the  very  centre  the  underlying  bone  is  left  bare  or  is 
covered  by  fibrous  tissue  and  fibro-cartilage,  and  becomes  denser  in 
structure.  Grinewetsky/  who  experimented  on  dogs,  says  he  never 
found  a  lining  of  periosteum  or  cartilage  inside  the  new  acetabulum ; 
the  bone  was  always  sclerosed.  He  also  notes  the  absence  of  endothe- 
lium on  the  inner  surface  of  the  new  capsule. 

The  ossification  may  pass  beyond  the  usual  limits  and  include  por- 
tions of  the  capsule,''  forming  bony  stalactites,  or  even  a  complete 
bony  case  enveloping,  and  perhaps  united  with,  the  head  of  the  bone;" 
and  in  a  specimen  presented  by  Moreau,^  a  dislocation  of  the  femur 
into  the  obturator  foramen,  the  membrane  filling  the  foramen  had  been 
transformed  into  a  bony  plate  throughout,  except  in  a  strip  along  its 
anterior  margin. 

Some  of  these  experimental  observations  have  been  repeated  upon 
specimens  of  ancient  dislocations  in  man,  in  some  of  which  the  new 
cavity  has  been  found  to  be  lined  with  fibro-cartilage,^  in  others 
with  a  granular  fibroid  tissue  without  apparent  cartilage  of  incrus- 
tation.^ 

The  displaced  head  shows  changes  varying  in  extent  and  consisting 
in  loss  of  its  cartilage,  erosion  of  the  bone  in  places  and  its  increase  in 
others,  and  occasionally  in  profound  changes  of  structure  throughout. 
Thus  in  the  case  just  referred  to,  reported  by  Duguet,  a  dislocation 
inward  of  the  shoulder  of  six  months'  standing,  the  head  of  the 
humerus  was  worn  away  behind  at  the  point  where  it  rested  against 
the  rim  of  the  glenoid  cavity,  which  also  had  in  great  part  disappeared  ; 
its  anterior  portion  had  preserved  its  cartilage  at  almost  all  points, 
while  its  posterior  portion  had  none,  it  being  there  replaced  by  rather 
tight,  short  fibrous  bands  uniting  the  head  to  the  old  glenoid  cavity. 
In  a  specimen  presented  by  Walsh  ^  to  the  Royal  Surgical  Society  of 
Ireland,  April  25,  1840,  of  an  old  dislocation  of  the  shoulder  forward, 
the  subscapularis  muscle  was  raised  from  the  scapula  by  the  head  of 
the  humerus,  the  new  glenoid  cavity  was  covered  by  fibro-cartilage, 
the  synovial  sac  was  complete,  and  the  cartilage  of  the  humerus  perfect. 
Old  backward  dislocations  of  the  elbow  (5.  v.)  often  show  a  very  com- 
plete new  radio-humeral  joint. 

The  empty  glenoid  or  cotyloid  cavity  diminishes  gradually  in  size 
either  by  absorption  of  that  portion  against  which  the  head  of  tlie  bone 
rests  or  by  a  general  atrophy,  presumably  due  to  its  disuse,  similar  to 
that  observed  in  the  alveolar  process  after  removal  of  the  teeth,  and 
its  cavity  fills  up  with  fibrous  tissue  that  springs  from  and  replaces  its 
lining  cartilage.  The  glenoid  cavity  has  in  some  cases  been  still  farther 
rendered  unfit  for  use  and  inaccessible  by  union  with  the  outer  portion 
of  the  original  capsule,  when  that  has  been  drawn  across-  its  face  as  the 
humerus  was  displaced  inward.     And  yet,  occasionally  the  acetabulum 

I  Grinewetsky  :  Centralblatt  fiir  Chirurgie,  1879,  p.  279. 

*  Thore  :  Bull,  de  la  Soc.  Anatomique,  1839,  p.  33. 

3  Cooper:  Loc.  cit.,  p.  50;  and  Cruveilhier:  Anat.  patlioL,  vol.  i.  p.  425. 

*  Moreau :  Mem.  de  I'Acad.  royale  de  Chirurgie,  1769,  vol.  ii.  p.  153. 
°  Lepine  and  Desormeaus:  Bull,  de  la  Soc.  Anat.,  1844,  p.  167. 

«  Duguet :  Bull,  de  la  Soc.  Anat.,  1863,  p.  144. 
''  Walsh  :  Gazette  des  Hopitaux,  1840,  p.  330. 


PATHOLOGY  OF   UNREDUCED  FRACTURES.  507 

has  remained  empty,  and  its  cartilage  unchanged  for  many  years  (Dreh- 
mann).^ 

When  the  use  made  of  the  limb  is  very  slight  and  the  head  of  the 
bone  is  immovably  fixed  in  its  new  position,  the  development  of  artic- 
ular characteristics  is  slighter  and  the  bone  may  even  diminish  nota- 
bly in  size  or  consistency,  as  in  the  case  quoted  on  page  499,  in 
which  the  head  of  the  humerus  passed  into  the  chest  and  remained 
fixed  there.  This  atrophy  of  disused  parts  is  a  general  rule,  and 
although  observed  in  bone  is  more  marked  in  other  tissues  whose  nutri- 
tive changes  and  functional  activity  are  greater.  In  accordance  with 
this  general  law  the  muscles  which  are  rendered  inactive  by  the  greater 
or  less  fixation  of  the  dislocated  bone  diminish  in  size,  and  if  their 
inactivity  is  complete,  or  even  nearly  so,  their  fibres  undergo  an  actual 
degeneration  and  their  fibrous  tissue  predominates  to  such  an  extent 
that  they  are  hardly  more  than  ligaments.  The  bone,  too,  is  similarly 
affected  throughout  its  entire  length  ;  it  becomes  smaller,  or,  if  the 
dislocation  has  occurred  during  youth,  before  development  is  complete, 
it  fails  to  develop  to  the  same  extent  as  its  fellow  on  the  opposite  side, 
and  even  its  normal  curves  disappear. 

These  facts  show  both  the  danger  and  the  futility  of  attempts  to 
reduce  dislocations  that  have  long  existed ;  they  show  that  reduction 
can  be  accomplished  only  at  the  cost  of  lacerations  far  more  extensive 
than  those  involved  in  the  original  injury,  that  among  these  lacera- 
tions may  be  included  rupture  of  important  vessels  or  nerves  that  have 
become  adherent  to  or  included  in  the  fibrous  bands  of  new  formation, 
and  that  even  if  the  bone  can  be  successfully  liberated  from  its  attach- 
ments and  brought  back  to  the  cavity  from  which  it  was  displaced  the 
latter  may  have  become  entirely  unfit  for  its  reception  and  for  a  resump- 
tion of  its  own  original  functions. 

Important  changes  in  the  condition  of  the  limb  may  be  caused  by 
pressure  upon  the  bloodvessels  or  nerves  by  the  displaced  bone  or  by 
injury  done  them  during  attempts  at  reduction.  Instances  of  the  latter 
are  given  in  Chapter  XXXIV. 

Persistent  oedema,  resulting  in  a  condition  resembling  elephantiasis, 
was  observed  by  Bartels^  in  a  patient  whose  shoulder  had  been  dislo- 
cated for  more  than  a  year.  There  was  also  rigidity  of  the  fingers  in 
a  position  indicating  ulnar  paralysis,  which  was  relieved  by  increasing 
the  mobility  of  the  shoulder,  but  the  oedema  persisted. 

For  a  detailed  study  of  these  changes,  as  observed  at  the  shoulder, 
elbow,  and  hip,  see  Delbet  {Arch.  gm.  de  Med,  1893,  p.  19)  and 
Dollinger  [Ergebnisse  der  Chir.  und  Orthop.,  1911,  vol.  iii.). 

1  Drelnuauii  :  Beitriige  zur  kliu.  Chir.,  1897,  vol.  xvii. 
'  2  Bartels :  Arch,  fiir  kliu.  Chir.,  1874,  vol.  xvi.  p.  0)38. 


CHAPTER   XXXI 


SYMPTOMS   AND   DIAGNOSIS. 


The  symptoms  of  a  dislocation — those  changes  in  the  form,  functions, 
and  sensibility  of  the  part  by  which  the  presence  of  a  dislocation  is  recog- 
nized— are  classed  as  objective  and  subjective  or  rational.  The  former, 
which  alone  are  deemed  demonstrative,  are  those  which  can  be  recog- 
nized by  the  surgeon  on  examination  ;  the  latter  are  those  for  his  knowl- 
edge of  which  he  must  depend,  to  a  greater  or  less  extent,  upon  the 
statements  of  the  patient. 

The  examination  of  the  patient  should  always  be  conducted  sys- 
tematically, with  the  view  to  learn  not  merely  the  existence  of  the 
dislocation,  but  also  such  details  and  complications  as  may  be  present 
and  may  affect  the  treatment  and  prognosis ;  and  it  should  include  an 
examination  of  the  condition  of  such  bloodvessels  and  nerves  as  may 
have  been  injured  at  the  same  time,  in  order  that  such  injuries,  if  their 
later  consequences  should  become  manifest,  may  not  be  attributed  to 
the  treatment.  If  swelling,  a  large  amount  of  subcutaneous  fat,  or 
pain  should  prevent  a  satisfactory  examination,  anaesthesia  should  be 
employed.  The  character  and  direction  of  the  force  that  produced  the 
dislocation  should  be  learned,  and  also,  if  possible,  the  position  of  the 
limb  at  the  moment  of  its  dislocation,  and  whether  a  "  consecutive  " 
has  been  substituted  for  a  "primary"  displacement,  or,  as  evidence  of 
the  latter  fact,  whether  one  fixed  position  of  the  limb  has  been  sub- 
stituted for  another.  In  doubtful  cases  the  uninjured  limb  should  be 
used  for  comparison,  and  the  question  should  be  asked  whether  or  not 
the  suspected  joint  has  been  previously  the  seat  of  disease  or  injury  the 
consequences  of  which  may  affect  the  conclusions  to  be  drawn  from 
the  examination.  The  essential  point  in  the  examination  is  to  deter- 
mine the  position  of  the  end  of  the  bone,  its  relations  to  that  one  from 
which  it  is  thought  to  have  been  violently  separated,  and  the  best 
evidence  of  this  fact  is  furnished  by  feeling  the  end  of  the  bone  with 
the  fingers,  by  tracing  its  outline,  by  feeling  it  move  when  the  lower 
part  of  the  limb  is  moved. 

Objective  Signs. 

Deformity.  Beside  the  attitude  of  the  patient  or  of  the  limb,  which 
is  often  strikingly  characteristic,  the  aspect  of  the  region  of  the  affected 
joint  is  changed  by  the  inflammatory  swelling,  which  may  appear 
promptly  or  tardily  and  be  accompanied  by  ecchymosis  and  by  altera- 
tions in  the  depth  or  position  of  the  fold  of  its  flexure  and  in  its  normal 
depressions  and  prominences.  The  swelling  varies  with  the  length  of 
(508) 


SYMPTOMS  AND  DIAGNOSIS  509 

time  that  has  elapsed  since  the  injury  was  received,  increasing  for  a  day 
or  two,  remaining  stationary  for  a  variable  time,  and  then  diminishing  ; 
in  old  cases  the  region  is  atrophied.  If  the  dislocation  has  been  caused 
by  external  violence  acting  directly  upon  the  region  of  the  joint,  the 
swelling  is  increased  by  the  eifects  of  the  contusion,  and  ecchymoses 
appear  more  promptly  than  in  other  cases. 

The  position,  with  reference  to  each  other,  of  the  articular  surfaces 
or  ends  which  constitute  the  joint  can  often  be  determined  by  palpation, 
and  this  furnishes  the  most  exact  and  positive  evidence  of  the  character 
of  the  injury.  In  joints  that  are  not  thickly  overlain  by  soft  parts  or 
masked  by  swelling  or  extravasated  blood,  this  position  can  be  readily 
made  out,  as  at  the  knee,  fingers,  elbow,  or  even  the  shoulder ;  at  the 
hip  it  is  easy  in  some  dislocations — e.  g.,  suprapubic — to  recognize  the 
head  of  the  femur,  in  others  it  is  much  more  difficult. 

If  the  head  of  the  bone  cannot  be  felt,  its  position  (if  there  is  no 
fracture)  can  be  determined  from  that  of  its  shaft  and  recognizable 
prominences  or  apophyses.  Thus,  if  the  great  trochanter  can  be  recog- 
nized, the  position  of  the  head  of  the.  femur  can  be  readily  inferred  by 

Fig.  363.  Fig.  364. 

F   


Diagram  to  show  the  effect  of  position  upon  the  appar-  Diagram  to  show  the  action  of  a  liga- 
ent  length  of  the  arm  in  dislocation  of  the  shoulder.  A,  ment  in  limiting  the  range  of  motion 
acromion ;  B,  lower  end  of  humerus ;  C,  head  of  humerus,      in  a  dislocation. 

prolonging  from  it  in  imagination  the  neck  of  the  femur  in  the  line 
indicated  by  the  position  of  the  shaft.  In  like  manner  prolongation 
upward  of  the  line  of  the  lower  portion  of  the  humerus  indicates  the 
position  of  the  head  of  the  bone,  and  if  it  passes  to  the  inner  side  of 
the  acromion  the  shoulder  must  be  dislocated  or  the  bone  broken. 

The  continuity  of  the  supposed  head  with  the  shaft  is  determined  by 
recognizing  that  it  participates  in  slight  movements  communicated  to 
the  lower  segment  of  the  limb.  By  prolonged  firm  pressure  with  the 
fingers  an  inflammatory  swelling  may  sometimes  be  pushed  aside  and 
the  bone  distinctly  felt. 

The  limb  may  appear  to  be,  or  may  actually  be,  shortened  or  lengtii- 
ened,  but  this  sign  is  not  of  so  much  value  as  it  is  in  cases  of  fracture, 
both  because  it  varies  greatly  with  varying  positions  of  the  limbs  and 
because  the  limbs  cannot  always  be  placed  symmetrically.  The  reason 
why  the  length  of  the  measured  distance  varies  in  different  positions 
of  the  limb  can  be  made  clear  by  taking  an  example,  as  the  shoulder. 


510 


DISLOCATIONS. 


Here  the  distance  usually  measured  is  that  from  the  edge  of  the  aero 
mion  to  the  external  epicondyle  of  the  humerus.  Now,  this  distance 
diminishes  as  the  arm  is  abducted,  for  (Fig.  363)  when  the  arm  hangs 
by  the  side,  the  line  A  B  is  almost  exactly  equal  to  C  B  plus  the  dis- 
tance that  C  lies  below  the  level  of  A;  while,  on  the  other  hand,  when 
the  arm  is  abducted  the  distance  A  B'  is  equal  to  C  B  minus  the  dis- 
tance of  C  beyond  the  line  of  A. 

The  methods  of  measuring  and  the  precautions  to  be  taken  are  the 
same  as  in  the  case  of  fracture  and  have  been  elsewhere  considered  ;  and 
the  possibility  of  the  previous  existence  of  asymmetry  of  the  limbs,  of  a 
difference  in  their  length,  has  also  been  described.     (Fractures,  p.  53.) 

Loss  of  Mobility.  In  almost  every  dislocation  there  is  a  position 
which  is  characteristic  of  it  and  which  the  limb  tends  spontaneously 
to  assume  and  retain,  even  under  anaesthesia.  This  position  depends 
rather  upon  the  tenseness  of  ligaments  and  untorn  portions  of  the  cap- 
sule than  upon  the  muscles,  although  the  latter  by  being  already  over- 
stretched may  aid  in  limiting  motion  or  change  of  position  in  certain 
directions.  The  head  of  the  bone  takes  up  a  new  position  at  some 
distance  from  its  normal  one  and  there  establishes  a  new  centre  of 
motion  for  the  limb  ;  consequently  the  ligaments  on  the  side  opposite 
that  toward  which  the  head  has  been  displaced  are  put  upon  the  stretch 
if  the  attempt  is  made  to  move  the  lower  part  of  the  bone  in  the 
same  direction,  and,  unless  torn,  fix  it  at  an  angle  with  the  other 
bone  to  which  they  are  attached  (Fig.  364).  The  bone  can  be  moved 
toward  the  attachment  of  the  untorn  ligament  but  not  further  away 
from  it. 

Since  the  limitation  of  motion  has  its  principal  cause  in  the  non- 
muscular  structures,  it  cannot  be  entirely  removed  by  ansesthesia,  but 
such  additional  limitation  as  may  be  due  to  contraction  of  the  muscles 
excited  by  the  fear  of  pain  can  be  thus  removed,  and  whenever  the 
fixity  of  a  limb  is  used  as  an  element  in  making  the  diagnosis  the  part 
taken  by  the  muscles  in  its  production  should  be  determined.  The 
diagnostic  formula  sometimes  given  that  abnormal  fixation  is  charac- 
teristic of  dislocations,  and  abnormal  mobility  of  fractures,  is  a  partial 
statement  that  may  be  misleading,  for  in  fracture,  or  even  in  contusion, 
near  a  joint  complete  fixation  may  be  effected  by  the  muscles,  and  in 
dislocation  with  extensive  laceration  of  the  capsule  and  ligaments  the 
range  of  motion  may  be  very  wide,  and  in  all  it  is  generally  free  in 
some  direction. 

A  therapeutical  fact  that  may  often  be  of  importance  is  to  be  deduced 
from  the  fact  that  the  dislocation  must,  in  most  cases,  have  taken  place 
when  the  limb  was  in  one  of  the  positions  in  which,  while  still  dislo- 
cated, it  is  shortened — that  is,  one  in  wdiich  the  distance  from  its  normal 
opposing  articular  surface  to  its  lower  end  is  less  than  that  between  the 
corresponding  points  of  the  opposite  limb  in  a  similar  position  ;  by 
replacing  the  limb  in  the  position  it  occupied  when  the  dislocation  took 
place  the  first  step  in  reduction,  that  of  bringing  the  head  of  the  bone 
opposite  the  rent  in  the  capsule  through  which  it  has  escaped  and  relax- 
ing the  soft  parts,  is  taken. 


SYMPTOMS  AND  DIAGNOSIS.  511 

Crepitus.  A  sound  or  sensation  somewhat  resembling  the  crepitus  of 
a  fracture  is  occasionally  perceived  while  a  dislocated  limb  is  being 
handled.  It  may  be  the  real  crepitus  of  a  fracture  accompanying 
the  dislocation,  or  merely  the  grating  of  the  head  of  the  bone  against 
the  edge  of  the  periosteum  of  the  other,  or  against  a  fibrous  band,  or 
even  (it  is  said)  against  a  blood-clot. 

Subjective  Symptoms. 

Pain.  The  occurrence  of  the  dislocation  is  immediately  followed  by 
sharp  pain  in  the  region  of  the  joint,  which  may  gradually  diminish  or 
may  continue  for  some  time  with  unabated  severity.  In  the  former  case 
it  is  presumably  due  in  great  part  to  the  laceration  and  bruising  of  the 
tissues ;  in  the  latter  to  the  tension  of  those  parts  that  have  not  yielded 
to  the  strain.  In  the  former  case  the  pain  is  not  materially  relieved 
by  reduction  ;  in  the  latter  it  immediately  disappears  when  the  bone  is 
restored  to  its  place.  In  addition  to  this  pain  about  the  joint,  there 
may  also  he  tingling  or  numbness  through  the  limb  in  consequence  of 
pressure  upon  the  large  nerve  trunks. 

Loss  of  Function.  Inability  to  use  the  limb  is  ordinarily  complete, 
and  is  due  partly  to  the  fixation  created  by  the  changed  relations  of  the 
bones  and  partly  to  the  pain  which  movement  causes.  There  is  noth- 
ing characteristic  in  this  symptom,  since  it  is  present  also  aftei'  fracture 
and  even  after  a  severe  contusion.  Furthermore,  it  is  sometimes  absent, 
or  present  in  so  slight  a  degree  that  the  patient  continues  to  use  tiie 
limb,  conscious  only  of  some  slight  pain  and  of  a  certain  inconve- 
nience or  lack  of  freedom  in  its  use. 

History.  The  history  of  the  case  includes  the  character  of  the  vio- 
lence, the  position  of  the  limb  at  the  moment  of  the  accident,  possibly 
the  perception  by  the  patient  at  that  moment  of  a  sound,  of  the  sensa- 
tion of  displacement,  and  the  history  of  any  previous  injury  to  or  dis- 
ease of  the  part  or  of  the  opposite  limb  so  far  as  it  may  affect  its  use 
for  the  purpose  of  comparison.  It  is  well  to  obtain  this  history  before 
proceeding  to  the  direct  examination  of  the  limb. 

There  can  be  no  uncertainty  as  to  the  main  fact  if  the  relations  to 
each  other  of  the  articular  ends  can  be  made  out,  and  the  surgeon 
should  not  rest  content  with  less  than  this  when  it  can  possibly  be 
attained.  In  every  doubtful  case  an  anaesthetic  should  be  employed, 
and  among  the  doubtful  cases  are  those  in  which  there  is  the  possible 
coexistence  of  a  fracture  either  of  a  portion  of  the  articular  surface  or 
of  the  entire  breadth  of  the  bone  near  the  joint.  The  latter  form  of 
fracture  is  itself  the  one  with  which  a  dislocation  is  most  frequently 
confounded  ;  either  may  be  mistaken  for  the  other  ;  and  in  any  such 
case,  every  effort  should  be  made  to  determine  the  exact  positions  occu- 
pied by  the  ends  of  the  bones. 

In  dislocations  complicated  by  fracture  of  portions  of  the  articular 
surface  or  of  tuberosities  to  which  muscles  are  attaclied,  the  coexistence 
of  the  fracture  is  often  incaj)ablc  of  demonstration  and  can  only  be 
suspected  because  of  the  fticility  with  which  the  dislocation  recurs  after 
reduction. 


512  DISLOCATIONS. 

Such  complications  as  injury  of  a  main  bloodvessel  or  nerve  will  be 
readily  recognized  by  attention  to  the  characteristic  symptoms  to  which 
they  give  rise. 

Finally,  it  should  be  remembered  that  the  most  experienced  and  care- 
ful surgeons  have  sometimes  remained  in  doubt,  or  have  denied  the 
existence  of  a  dislocation  which  the  subsequent  course  of  the  case  has 
shown  to  have  been  present,  and  the  charity  which  the  critic  may  him- 
self so  soon  need  should  be  cordially  extended  to  others. 


CHAPTER  XXXII. 


COURSE  AND  PROGNOSIS. 


If  the  dislocation  is  promptly  reduced  and  no  complications  are 
present,  the  course  is  simple  and  the  prognosis  favorable.  The  swell- 
ing and  pain  subside,  and  the  patient  is  soon  able  again  to  use  the  limb, 
although  usually  with  some  limitation  of  the  range  of  motion  and  with 
pain  when  these  limits  are  reached.  This  slight  disability  may  persist 
for  weeks,  or  even  months,  especially  in  those  who  are  constitutionally 
prone  to  arthritic  complications.  I  have  known  a  robust,  thoroughly 
healthy  man  to  dislocate  his  shoulder,  the  dislocation  being  so  slight 
that  it  was  immediately  reduced  by  accidental  traction  on  the  arm  and 
he  was  able  to  use  the  limb  without  a  day's  intermission  ;  and  yet, 
three  months  after  the  accident  he  was  unable  to  lift  the  elbow  in 
abduction  to  the  level  of  the  shoulder,  and  could  not  carry  his  hand  to 
his  hip-pocket  without  causing  considerable  pain. 

If  the  inflammatory  reaction  is  more  severe,  the  jmin  and  swelling 
are  greater  and  more  prolonged,  and  the  limitation  of  movement  may 
become  permanent  through  the  formation  of  adhesions  or  the  conden- 
sation and  thickening  of  the  peri-articular  soft  parts.  It  is  very  excep- 
tional for  this  process  to  go  on  to  suppuration. 

If  the  disarticulation  is  compound,  it  may  follow  either  one  of  two 
courses  ;  either  it  is  transformed  into  a  simple  one  by  the  prompt  union 
of  the  wound,  or  suppuration  ensues  and  the  patient  is  exposed  to  all 
the  accidents  of  a  deep  suppurating  wound,  rendered  all  the  more  exten- 
sive by  its  continuity  wdth  the  interior  of  the  joint.  In  the  latter  case 
the  result  is  certain  to  be  marked  by  much  functional  disability,  per- 
haps by  total  loss  of  mobility  in  the  joint. 

Other  complications  add  to  the  otherwise  uneventful  course  of  a 
simple  dislocation  the  features  peculiar  to  themselves;  thus,  injury  to 
a  nerve  may  be  followed  by  temporary  or  permanent  paralysis  of  the 
muscles  or  loss  of  sensation  in  the  region  supplied  by  it,  Or  by  a  long 
train  of  symptoms  indicating  an  ascending  neuritis.  And  injury  to  a 
main  artery  may  be  followed  by  gangrene  of  the  limb,  or  by  the  forma- 
tion of  a  traumatic  or  encysted  aneurism.  The  coexistence  of  a  fracture 
of  the  neck  of  the  bone  creates  a  condition  which  for  a  time  predomi- 
nates over  the  dislocation ;  if  the  latter  is  promptly  reduced  the  case 
follows  essentially  the  course  of  a  fracture;  if  it  cannot  be  at  once 
reduced  the  course  at  first  is  still  in  the  main  that  of  a  fracture,  and 
subsequently  that  of  an  old  dislocation. 

The  fracture  of  a  portion  of  the  articular  edge,  or  of  an  :i})ophysis, 
is  habitually  followed  by  no  symptoms  peculiar  to  itself,  excej>t  in  some 
cases  a  marked  tendency  to  recurrence  of  the  dislocation  after  its  reduc- 
tion, and  this  tendency  may  persist  throughout  life. 

Excluding  these  complications,  the  prognosis  in  a  simjile  dislocation 

(513) 


514  DISLOCATIONS. 

of  a  limb,  quoad  vitam,  is  eminently  favorable  ;  the  prognosis  with 
regard  to  the  restoration  of  form  and  functions  depends  upon  the 
reducibleness  of  the  dislocation,  and  this  is  affected  by  the  character 
of  the  joint  and  of  the  injury,  by  complications,  and  by  the  time  that 
has  elapsed  since  the  injury  was  received. 

The  principal  obstacle  to  the  reduction  of  a  dislocation  commonly 
lies  in  the  tension  of  the  untorn  portion  of  the  capsule  and  ligaments, 
but  s^jecial  difficulties  may  arise  from  the  relations  of  the  displaced 
bone  to  the  capsule  and  to  various  muscles  and  tendons.  The  capsule 
may  slip  in  between  the  head  of  the  bone  and  the  cavity  it  has  left, 
and  create  an  obstacle  (by  its  interposition)  that  cannot  be  removed  by 
manipulation  or  traction  of  the  limb,  or  its  torn  edge  may  be  drawn 
tightly  about  the  neck  of  the  bone,  as  is  common  at  the  metacarpo- 
phalangeal joint.  The  cases  in  which  the  former  happens  are  those 
in  which  the  capsule  is  freely  torn  at  or  near  its  attachment  to  the 
humerus  or  femur,  and  in  which  the  head  of  the  bone  is  displaced 
entirely  to  the  outside  of  the  capsule. 

The  greater  the  length  of  time  since  the  occurrence  of  the  disloca- 
tion, the  greater  will  be  the  difficulty  of  reduction  ;  and  after  the  lapse 
of  a  certain  length  of  time,  which  is  different  in  different  cases,  reduc- 
tion becomes  impossible.  The  cause  of  this  difficulty  has  been 
described  in  Chapter  XXX. 

The  period  at  which  a  dislocation  is  to  be  deemed  unfit  for  reduc- 
tion cannot  be  positively  stated ;  it  varies  with  different  joints  and 
different  cases.  Speaking  generally,  it  is  about  two  months  for  the 
larger  joints,  but  it  is  not  prudent  to  assume  that  any  dislocation  which 
has  remained  unreduced  for  a  shorter  period  than  two  months  is  re- 
ducible, or  that  every  one  that  is  older  is,  therefore,  irreducible ;  for  in 
the  former  case  we  may  be  led  to  apply  an  amount  of  force  that  will 
prove  disastrous  and  in  the  latter  disabilities  that  are  amenable  to 
treatment  may  be  left  unrelieved.  A  better  guide  is  to  be  found  in 
an  examination  directed  to  ascertaining  the  changes  produced  in  the 
parts  by  the  original  injury  or  the  disuse,  and  in  careful,  judicious 
attempts  to  make  reduction.  The  object  of  these  attempts  should  not 
be  to  reduce  the  dislocation  at  any  cost,  but  to  reduce  it  only  if  the 
reduction  can  be  accomplished  by  moderate  force  and  without  grave 
lacerations.  And,  indeed,  I  am  convinced  that  in  a  doubtful  case  it  is 
better  to  expose  the  bone  by  incision,  and  divide  the  obstructing  tissues 
with  the  knife,  rather  than  blindly  to  rupture  them  by  the  application 
of  a  force  whose  action  cannot  be  intelligently  directed,  and  whose 
effects  cannot  be  certainly  foreseen  and  controlled.  That  the  warning 
is  still  needed  is  shown  by  the  recent  (1897)  death  of  a  patient  in  the 
New  York  Hospital  after  an  attempt  to  reduce  a  dislocation  of  the 
shoulder  of  six  weeks'  standing  by  traction  and  manipulation  which 
ruptured  the  axillary  vein  and  broke  the  third,  fourth,  and  fifth  ribs. 

Encouragement  to  attempt  reduction  even  M'hen  the  dislocation  has 
remained  unreduced  for  a  period  nuich  longer  than  that  of  two  months 
above  mentioned  is  furnished  by  not  a  few  recorded  cases  in  which  it 
has  been  completely  successful ;  instances  will  be  given  in  the  follow- 
ing chapter. 


CHAPTEK  XXXIII. 

TREATMENT. 

Spontaneous     Reduction — Obstacles    to   Reduction — Anaesthesia — Methods  of 
Reduction — Old  Dislocations — After-treatment — Habitual  Dislocation. 

Ae  a  rule,  to  whicli  there  can  be  very  few  exceptions,  reduction  of 
a  dislocation  should  be  attempted  at  the  earliest  opportunity.  The 
possible  exceptions  are  cases  in  which  the  inflammatory  reaction  is 
already  very  great,  and  in  which  it  may  be  antici])ated  that  the  addi- 
tional violence  inflicted  during  reduction  would  dangerously  increase 
it.  But  even  in  such  cases  it  would  be  well  to  make  gentle  efforts  to 
reduce  under  ether,  and  to  postpone  the  reduction  only  if  these  efforts 
proved  unavailing. 

Spontaneous  reduction  is  the  term  ap])lied  to  that  which  takes  place 
without  the  intentional  intervention  of  any  external  force.  It  may 
take  place  while  the  patient  is  asleep,  through  the  action  of  the 
attached  muscles  or  through  some  chance  violence,  or  by  a  fall  or  a 
sudden  movement. 

Spontaneous  reduction,  without  the  aid  of  external  force,  has  fol- 
lowed shortly  after  attempts  to  reduce  which  have  been  unsuccessful 
but  which  may  be  thought  to  have  made  spontaneous  reduction  pos- 
sible by  rupture  of  adhesions,  or  laceration  of  the  tissues,  or  fatigue 
of  the  muscles.  This  variety  was  termed  consecutive  reduction  by 
Leveille,  and  the  term  was  adopted  by  Malgaigne,  who  applied  it  both 
to  cases  in  which  spontaneous  reduction  takes  place  after  complete 
failure  of  the  efforts  to  reduce  and  also  to  those  in  which  an  incom- 
plete reduction  spontaneously  becomes  complete  or  is  gradually  made 
complete  by  prolonged  action  of  some  force  applied  by  the  surgeon  — 
such  as  pressure. 

The  obstacles  to  the  reduction  of  recent  uncomplicated  dislocations 
arise  from  inflammatory  swelling  of  the  soft  parts,  muscular  contrac- 
tion excited  by  pain  or  the  fear  of  pain,  the  inextensibility  of  untorn 
portions  of  the  capsule  or  ligaments  of  the  joints,  the  interposition  of 
portions  of  the  capsule  between  the  head  of  the  bone  and  its  cavity, 
and  the  size  and  position  of  the  rent  in  the  capsule.  Not  all  of  these 
are  present  in  every  case,  and  they  vary  in  im])ortance.  For  a  long 
time  the  muscles  were  deemed  the  most  important,  but  observations 
and  experiments  upon  the  cadaver  carried  on  at  about  the  same  time 
by  several  different  persons — Gunn  ^  in  1851,  Gelle"  and  Bigelow'^  in 
1861,  Streubel^  in  1862,  and  BuschMn  1863— flxcd  the  attention  of 

'  Gunn:  Peninsular  Journal  of  Medicine,  July,  1S55,  p.  27. 

2  Gelle  :  Archives  generales  de  Med.,  April  and  May,  ISfil. 

3  Bigelow  :  The  Hip. 

*  Streuhel:  Vierteljahrcschrift  fiir  prakt.  Heilkuude,  18G2,  vol.  ii.  p.  f>9. 

*  Eu.scli  :  Arch,  fur  klin.  Chirurgie,  18(J.3,  p.  1. 

(  515  ) 


516  DISLOCATIONS. 

surgeons  upon  the  relations  between  the  bone  and  the  capsule,  showed 
the  nature  and  importance  of  the  opposition  commonly  offered  by  the  lat- 
ter, and  established  the  basis  of  treatment  by  systematic  manipulation. 
An  account  has  already  been  given  of  the  part  played  by  the  untoru 
portion  of  the  capsule  in  determining  the  position  assumed  by  the  limb, 
a  part  so  important  that  in  "  regular  "  dislocations  (the  term  given  by 
Bigelow  to  those  in  which  the  rent  in  the  capsule  is  only  partial  and 
occupies  a  certain  definite  place  in  it)  the  muscles  surrounding  the 
joint  may  all  be  divided  without  thereby  modifying  the  position  of 
the  limb  or  increasing  its  range  of  motion.  At  the  hip  the  portion 
which  remains  untorn  in  all  the  typical  forms  is  the  anterior  portion 
or  Y-ligament;  at  the  shoulder  it  is  the  thicker  anterior  portion  form- 
ing the  so-called  coraco-humeral  ligament.  It  is  more  correct  to  speak 
of  the  obstacle  offered  to  reduction  by  this  untorn  portion  of  the  cap- 
sule as  an  obstacle  not  to  reduction  in  general,  but  only  to  reduction 
by  certain  methods,  for  when  properly  managed  it  offers  no  opposition, 

and  may  possibly  even  be  of  assistance.     It 
Fig.  365.  may  be  compared  to  the  link  of  a  sleeve- 

button,  whicli  in  some  positions  absolutely 
prevents  the  button  from  passing  back 
through  the  button-hole,  while  in  other 
positions  the  passage  is  easy.  Thus,  if  the 
head  of  the  bone  is  lodged  behind  a  pro- 
jecting portion  of  the  rim  of  the  articula- 
tion, the  ligament  (Fig.  365)  is  tense,  and 
traction  in  any  direction  wliich  tends  to 
separate  its  points  of  attachment  is  effectu- 
ally opposed  by  it ;  but  if  these  points  are 
brought   nearer  together   by    moving   the 

Diagram  to  illustrate  the  action       ^^^^^  ^f  ^j^^  ^^^^  -^^  ^|^g  direction  indicated 
of  an  untorn  ligament  or  portion       ,  ,  it  •         i  i 

of  capsule  in  opposing  reduction.  by  the  arrow,  the  hgament  is  thereby  re- 
laxed and  its  opposition  to  the  movement 
of  the  head  of  the  bone  toward  its  cavity  annulled.  The  position  of 
the  untorn  portion  of  the  capsule  or  ligament  must  be  inferred  from 
the  posture  of  the  limb  and  the  directions  in  which  motion  is  strongly 
opposed. 

In  "irregular"  dislocations,  those  ia  which  a  characteristic  attitude 
is  not  taken  by  the  limb  and  in  which  the  mobility  is  marked,  these 
differences  are  due  to  extensive  rupture  of  the  capsule ;  and  this,  by 
removing  the  restraint  imposed  in  other  cases  by  the  untorn  portion 
of  the  capsule,  makes  reduction  remarkably  easy  without  much  atten- 
tion to  the  position  in  which  the  limb  is  held  during  the  attempt. 

In  addition  to  this  opposition  to  movement  or  traction  in  certain 
directions,  the  capsule  may  offer  other  obstacles  arising  from  the  form 
and  position  of  its  rent  and  from  its  own  interposition  between  the  head 
of  the  bone  and  the  cavity  in  which  the  latter  is  to  be  replaced.  The 
tearing  of  the  capsule  is  caused  by  the  pressure  of  the  head  upon  it, 
consequently  th^  rent  is  on  the  side  toward  which  the  head  is  displaced, 
and  it  may  be  longitudinal  or  transverse  at  either  attachment,  or  present 
a  combination  of  the  two  forms.    In  order  that  either  of  these  obstacles 


TREATMENT.  517 

should  be  present,  it  is  necessary  that  the  head  of  the  bone  should  have 
passed  entirely  through  the  rent — that,  in  other  words,  its  displacement 
should  be  marked.  As  the  rent,  under  these  circumstances,  is  large 
enough  to  allow  the  head  to  pass  out  through  it,  it  is  large  enough 
to  allow  it  to  be  brought  back  through  it  if  it  is  not  made  too 
narrow  and  its  sides  too  tense  by  traction  upon  them.  The  effect  of 
traction  to  narrow  the  opening  can  be  demonstrated  on  the  cadaver 
(Streubel,  loc.  cit,,  p.  70)  by  producing  a  subcoracoid  dislocation  of  the 
humerus  or  an  obturator  or  ischiatic  dislocation  of  the  femur,  exposino- 
the  region  by  removal  of  the  muscles,  and  then  making  traction  in  the 
extended  position.  As  the  capsule  is  made  tense  the  sides  of  the 
longitudinal  part  of  the  rent  are  drawn  together,  and  their  lateral 
separation,  which  alone  would  allow  the  globular  head  of  the  bone 
to  pass  back,  is  prevented.  The  narrowness  of  the  gap  is  at  once 
relieved  by  changing  the  position  of  the  limb  in  such  a  manner  as 
to  bring  the  points  of  attachment  of  the  capsule  nearer  together,  and 
the  transverse  portion  of  the  rent  can  be  lengthened  by  rotating  the 
limb. 

Interposition  of  the  capsule  between  the  head  and  its  cavity  may 
exist  w^henever  a  secondary  displacement  has  succeeded  the  primary 
one  and  the  head  has  moved  from  the  point  at  M'hich  it  escaped  along 
the  outside  of  the  capsule,  but  unless  the  capsule  has  been  so  torn  as 
to  form  a  flap  adherent  by  its  base  to  the  edge  of  the  articular  cavity, 
this  interposition  can  be  readily  avoided  by  moving  the  head  of  the 
bone  back  to  the  position  of  primary  displacement.  If,  on  the  other 
hand,  such  a  flap  has  formed  and  has  fallen  between  the  articular  sur- 
faces, there  is  no  means,  short  of  an  operation  that  directly  exposes  it, 
of  certainly  getting  it  out  of  the  way ;  it  is  attached  to  only  one  bone, 
and  consequently  cannot  be  acted  upon  by  moving  the  other  or  changing 
the  relations  to  each  other  of  the  two. 

Swelling  of  the  soft  parts  interferes  with  reduction  by  increasing  the 
bulk  of  the  limb  within  the  fascia  and  thereby  mechanically  opposing 
changes  in  position.  If  it  is  very  great  it  may  be  proper  to  defer 
reduction  and  combat  the  swelling  by  rest,  cooling  lotions,  and  press- 
ure ;  it  will  usually  subside  so  promptly  that  the  loss  of  time  thus 
incurred  will  not  add  appreciably  to  the  difficulty  of  reduction  when 
it  is  undertaken. 

Contraction  of  the  muscles,  provoked  by  the  traumatism  or  the  fear 
of  pain,  opposes  reduction  by  preventing  the  preliminary  changes  of 
position  and  neutralizing  to  a  greater  or  less  extent  the  traction  that  is 
made  upon  the  limb.  It  may  be  overcome  by  gentle  and  long-continued 
traction,  or  forcibly,  or  by  anaesthesia,  or  it  may  be  avoided  by  taking 
the  patient  unawares  or  distracting  his  attention  at  the  critical  moment. 

Anaesthesia  is  far  from  being  needed  in  all  cases,  and  as  there  are 
certain  discomforts  and  even  dangers  in  its  use  an  attem})t  to  reduc^e 
without  its  aid  should  usually  be  made.  In  New  York,  and,  I  think, 
in  most  of  the  large  cities  of  the  United  States,  ether  is  liabitually  used 
in  preference  to  chloroform,  and  although  chloroform  is  still  used  in 
Europe,  the  greater  safety  of  ether  is  almost  universally  admitted. 
The  collected  cases  of  death  under  chloroform  apparently  proved  the 


518  DISLOCATIONS. 

correctness  of  an  opinion  quite  generally  held  that  its  use  in  disloca- 
tions is  especially  dangerous,  although  no  satisfactory  explanation  of 
the  fact  has  yet  been  given.  Of  101  fatal  cases  collected  by  Kappeler^ 
between  1865  and  1876,  11  were  dislocations,  20  amputations,  and  11 
operations  upon  the  eyes ;  of  134  cases  collected  by  Marchand,^  17  were 
dislocations,  and  15  extractions  of  teeth.  It  is  not  always  necessary 
to  push  the  use  of  ether  to  complete  ansesthetization,  for  the  relaxation 
is  sometimes  sufficient  during  the  stage  of  primary  ansesthesia  if  care 
is  taken  not  to  excite  the  patient  unduly.  Gentle  traction  may  be  made 
upon  the  limb  as  the  aneesthetization  is  begun,  and  its  direction  gradu- 
ally changed  or  merged  into  the  desired  manoeuvres  as  the  muscles  are 
felt  to  yield. 

Methods  of  Reduction. 

Since  the  nature  of  the  obstacles  to  reduction  has  been  more  correctly 
understood  the  methods  by  forcible  traction  have  been  so  far  superseded 
by  the  methods  of  manipulation  that  they  now  possess  only  an  histor- 
ical interest.  They  consisted  essentially  in  extension  (traction),  usually 
in  the  line  of  the  dislocated  limb,  and  counter-extension  to  bring  the 
head  of  the  bone  down  to  the  level  of  its  cavity,  followed  then  by 
measures  of  "  coaptation  "  to  force  it  into  place.  The  traction  was 
made  through  bands  attached  to  the  lower  segment  of  the  limb,  and 
the  force  was  exerted  either  directly  by  the  hands  of  several  assistants 
or  indirectly  through  pulleys  or  screws.  The  amount  of  force  some- 
times exerted  by  these  means  can  be  inferred  from  the  disastrous  and 
even  fatal  consequences  that  occasionally  ensued,  including  rupture  not 
only  of  muscles  and  ligaments  but  also  of  the  principal  nerves  and 
bloodvessels,  and  even  complete  avulsion  of  the  limb.  Suppuration 
of  the  joint,  followed  by  the  death  of  the  patient,  an  accident  which  is 
now  very  rare,  was  formerly  quite  common,  and  in  very  many  of  the 
cases  which  recovered  the  record  plainly  shows  the  violence  of  the 
reaction  and  how  narrowly  the  patients  escaped  with  their  lives.  The 
occasion  for  the  exertion  of  so  much  force  arose  from  the  faulty  direc- 
tion in  which  it  was  frequently  applied,  one  in  which  the  head  of  the 
bone  could  not  be  brought  down  to  the  level  of  the  cavity  without 
preliminary  rupture  of  the  opposing  soft  parts.  The  laceration  caused 
by  the  dislocation  was  increased  by  the  treatment,  in  order  to  enable 
the  bone  to  follow  a  course  which  the  ligaments,  if  untorn,  would 
effectually  bar.  The  method  was  directed  against  an  obstacle,  the 
resistance  of  the  muscles,  which  was  only  one,  and  that  not  the  chief,  of 
those  which  opposed  reduction,  and  was  pursued  in  ignorance  of  the 
principal  one  ;  violence  was  used  to  overcome  an  obstacle  whicli  correct 
anatomical  knowledge  would  have  enabled  the  surgeon  to  avoid. 

It  must  not  be  understood  that  this  extreme  violence  was  exerted  in 
every  case.  In  many  tlie  traction  was  made  in  a  proper  direction,  or 
at  least  in  one  in  which  the  already  existing  laceration  of  the  capsule 
allowed  the  bone  to  be  moved ;  hence,  many  dislocations  were  reduced 

1  Kvonlein  :  Loc.  cit.,  p.  66. 

2  Marchand  :  Des  Accidents  qui  peuveut  coiupliquev  la  ^Reduction  des  lAixatious  trau- 
matiqnes,  1875,  p.  134. 


TREATMENT.  519 

with  comparative  facility,  especially  those  of  the  shoulder  and  those  of 
the  hip  in  whi(!h  consecutive  displacement  had  not  materially  changed 
the  posture  of  the  limb,  and  in  such  cases  traction  was  a  proper  means 
to  overcome  the  opposition  of  the  muscles.  It  was  in  such  cases,  too, 
that  the  methods  of  continuous  moderate  traction  by  India-rubber, 
weight  and  pulley,  and  suspension  by  the  limb  ("  pendel-methode ") 
were  successfully  employed,  and  will  still  be  when  it  is  desired  to  avoid 
recourse  to  the  aid  of  anaesthesia. 

As  long  ago  as  in  the  time  of  Hippocrates  (fifth  century  b.  c.)  it 
had  been  known  that  some  dislocations  of  the  hip  could  be  readily 
reduced  by  manipulation  without  the  aid  of  violent  traction,  and  Galen 
(second  century  A.  D.)  had  pointed  out  that  the  head  of  the  bone 
should  be  returned  to  its  cavity  along  the  route  by  which  it  had  escaped, 
yet  these  suggestions  remained  unknown  or  unheeded  and  the  practice 
of  surgery,  as  regards  dislocations,  appears  to  have  been  not  only  inef- 
fectual to  relieve  in  a  large  pro})ortion  of  cases,  but  also  characterized 
by  dense  ignorance  of  their  pathology  and  by  the  crudest  notions  of 
the  mechanical  effects  of  the  means  by  which  their  reduction  was 
attempted.  Thus,  among  the  methods  in  vogue,  according  to  Petit, 
for  the  reduction  of  dislocations  of  the  shoulder,  at  the  beginning  of 
the  eighteenth  century,  were  those  of  the  door  or  ladder,  the  bar,  and 
the  ambi.  In  tlie  former  the  patient  was  made  to  stand  upon  a 
stool,  and  the  dislocated  arm  was  brought  over  the  top  of  a  door 
or  a  rung  of  a  ladder  so  that  the  latter  occupied  the  axilla ;  then, 
while  an  assistant  grasped  the  wrist  and  drew  it  directly  downward, 
the  stool  was  taken  away  and  the  patient  left  suspended  until  the  sur- 
geon pronounced  the  dislocation  reduced  or  abandoned  the  attempt.  In 
other  cases  the  patient  was  lifted  from  the  ground  upon  a  bar  supported 
on  the  shoulders  of  two  men  and  passing  under  his  axilla ;  or  a  large, 
strong  man  seized  the  patient's  wrist,  placed  his  own  shoulder  under 
the  axilla,  and  then  suddenly  straightening  himself  raised  the  patient 
from  the  ground,  at  the  same  time  drawing  the  arm  down  forcibly  in 
front  of  himself.  The  method  of  the  heel,  so  strongly  recommended  by 
Sir  Astley  Cooper,  was  also  em})loyed  by  them,  and  sometimes  with 
success. 

The  ambi,  an  instrument  invented  by  Hippocrates,  was  also  in  favor ; 
it  consisted  of  two  oblong  pieces  of  wood  joined  together  at  the  end  by 
a  hinge,  of  which  one  was  placed  vertically  against  the  side  of  the 
patient,  the  hinge  pressed  well  into  the  axilla,  the  other  under  the 
arm  in  the  position  of  horizontal  abduction.  The  arm  w'as  then  firmly 
secured  to  the  latter  piece  and  forcibly  depressed. 

As  the  defective  mode  of  action  of  these  methods  became  more  gen- 
erally recognized,  traction  by  the  hands  of  assistants  or  by  pulleys 
or  by  other  apparatus  was  substituted,  but  although  this  was  an  im- 
provement upon  its  barbarous  predecessors  it  Avas  still  cmj)loyed 
blindly,  and  evidently  was  often  ineffectual.  There  are  indications  in 
the  older  writings  that  the  practice  was  not  so  wholly  bad  as  the  teach- 
ing, that  here  and  there  men  were  found  who  not  only  appreciated  the 
importance  of  the  direction  in  which  traction  should  be  made,  but  even 
occasionally  reduced  dislocations  by  manipulation  alone,  but  the  writer 


520  DISLOCATIONS. 

who  seems  to  have  been  the  first  to  recognize  the  importance  of  the 
principle  enunciated  so  long  before  by  Galen  of  bringing  hack  the  head  of 
the  bone  bv  the  route  along  which  it  had  escaped,  and  of  the  position  to  be 
given  to  the  limb  during  the  attempt,  was  Jean  Louis  Petit.  His  Traite 
des  3Ialadies  des  Os  was  published  in  1705  ;  a  second  edition  followed 
in  1723,  and  a  third  in  1741.  He  clearly  pointed  out  the  mechanical 
defects  of  the  methods  then  in  use,  and  the  necessity  of  first  bringing 
the  head  of  the  bone  back  to  the  opening  in  the  capsule  through  which 
it  had  escaped  before  attempting  to  replace  it  in  its  cavity  ;  and  he  drew 
from  observation  of  the  different  degrees  of  tension  of  the  diflPerent 
muscles  inferences  as  to  the  position  in  which  the  limb  should  be  placed 
and  the  direction  in  which  traction  should  be  made,  which  were  of 
great  practical  value,  although  based  upon  notions  concerning  the 
obstacles  that  opposed  reduction  which  were  incomplete  in  that  they 
took  no  account  of  the  untorn  ligaments  and  capsule.  Thus,  in  dislo- 
cation forward  or  downward  of  the  shoulder  he  abducted  the  ell)Ow 
widely,  and  in  those  of  the  thigh  backward  he  flexed  the  limb  and 
then  changed  its  position  M'hen  the  head  of  the  bone  had  been  brought 
down  to  the  proper  level. 

Petit,  in  thus  departing  from  the  practice  of  his  predecessors  and 
contemporaries,  had  entered  upon  the  right  path  ;  he  erred  in  not  fol- 
lowing it  far  enough,  and  his  error  arose  from  a  too  limited  notion  of 
the  obstacles  to  be  overcome.  He  noticed  that  some  muscles  were  tense 
and  others  were  relaxed,  and  he  sought  to  place  the  limb  in  a  posture 
that  would  remove  these  differences,  while  at  the  same  time  traction 
made  in  the  direction  of  its  long  axis  would  bring  the  head  of  the  bone 
to  the  point  at  which  it  had  escaped  from  its  cavity.  His  improve- 
ments were  appreciated,  and  his  practice  was  essentially  followed  by 
most  surgeons  until  within  the  last  few  years.  Yet  one  of  his  early 
successors,  Pouteau,^  in  a  paper  embodying  ideas  conceived  in  1749 
(see  loc.  cit.,  vol.  ii.  p.  237),  pointed  out  the  defects  of  the  method  as 
applied  to  dislocations  of  the  hip,  and  supported  his  own  arguments 
and  modifications  by  the  record  of  several  successes.  He  says  (p.  222) 
that  in  the  first  case  of  dislocation  of  the  hip  upward  and  outward  (on 
the  dorsum  of  the  ilium)  which  he  was  called  upon  to  treat  he  em- 
ployed Petit's  method  and  failed.  That  is,  he  made  traction  with 
the  limb  somewhat  flexed,  counter-extension  being  furnished  by  the 
canvas  band  of  Petit's  machine,  the  centre  of  which  pressed  against 
the  tuberosity  of  the  ischium,  while  its  ends  lay,  one  in  front  of  the 
abdomen,  the  other  behind  the  buttock.  The  reflections  excited  by 
this  failure  led  him,  when  the  next  case  presented  itself,  a  few  months 
later,  to  make  traction  with  the  thigh  flexed  at  a  right  angle,  and  the 
effort  was  promptly  successful.  He  placed  the  patient  on  his  back  on 
the  floor,  laid  the  canvas  band  along  the  groin,  with  one  end  between 
the  thighs  and  the  other  on  the  outer  side  of  the  injured  hip,  flexed  the 
thigh  to  a  right  angle,  engaged  the  ends  of  tlie  bars  in  the  pockets  of 
the  counter-extending  band,  and  made  traction  ;  when  he  deemed  the 
traction  sufficient,  he  gently  rotated  the  thigh  outward,  and  reduction 
at  once  took  place.     Furthermore,  he  showed  that  the  resistance  of  the 

^  Pouteau  :  CEuvres  postliumes,  Paris,  1783.     Pouteau  died  in  1775. 


TREATMENT.  521 

muscles  was  due  to  their  iuvoluutary  contraction  and  was  to  be  more 
readily  and  safely  overcome  by  prolonged  moderate  traction  than  by 
more  violent  but  briefer  eiForts.  He  says  (loc.  cit.,  p  226) :  "  I  have 
several  times  observed  that  it  is  easier  to  temporize  than  immediately 
to  overcome  the  resistance  of  these  muscles ;  so,  when  the  extension 
seems  to  be  sufficient  I  maintain  it  at  the  same  point  for  some  time  and 
wait  for  the  relaxation  which  fatigue  must  bring  about.  It  is  then  only 
necessary  to  profit  by  this  moment  of  inaction  to  effect  the  reduction." 

Pouteau's  practice  closely  resembled  that  which  represents  the  appli- 
cation of  the  principles  of  the  modern  method  by  manipulation,  and  is 
identical  with  that  of  moderate  traction  upon  the  flexed  limb  which  is 
now  in  common  use  and  is,  I  think,  generally  preferred  to  that  of  pure 
manipulation.  He  flexed  the  limb  to  bring  the  head  of  the  bone  nearer 
the  opening  in  the  capsule,  made  traction  to  lift  it  to  the  level  of  the 
cotyloid  cavity,  and  then  turned  it  in  by  outward  rotation  or  abduction, 
or  both.  He  knew  even  that  the  traction  could  sometimes  be  dispensed 
with  and  the  reduction  effected  by  manipulation  alone,  and,  in  quoting 
successes  thus  obtained  by  Maisonneuve,  he  predicts  that  a  simpler 
method  than  his  own  will  be  found.  The  failure  of  his  practice  to 
become  generalized  is  probably  due  to  the  influence  of  tradition  and  of 
the  authority  of  Petit,  reinforced  as  the  latter  was  by  the  great  advance 
he  had  made  over  the  practice  of  his  predecessors,  and  perhaps  to  the 
insufficient  publication  of  Pouteau's  views.  The  paper  from  which 
the  above  quotations  are  made  appears  to  have  been  written  in  1749, 
but  there  is  no  evidence  that  it  was  published  elsewhere  tlian  in  the 
posthumous  collection  of  1783,  which,  consisting  of  disconnected  essays 
upon  various  subjects,  probably  had  only  a  limited  circulation.  "What- 
ever the  cause  may  have  been,  the  result  is  beyond  question  ;  surgeons 
continued  to  reduce  dislocations  of  the  hip  by  traction  with  the  pulleys, 
the  limb  being  only  slightly  flexed,  and  by  pressure  applied  at  the 
upper  part  of  the  thigh  to  move  the  head  laterally  into  the  cavity.  Sir 
Astley  Cooper  habitually  used  only  traction,  followed  by  rotation  of 
the  thigh  imvard. 

Prof.  Nathan  Smith,  of  New  Haven,  taught  and  practised  a  method 
of  reduction  by  manipulation  which  was  published  in  1831  after  his 
death,  in  his  Medical  and  Surgical  3Iemoirs,  edited  by  his  son,  Nathan 
R.  Smith,  and  this,  Prof.  Bigelow  says,  "  covers  the  ground  of  priority 
of  invention."     (See  Chapter  LI.,  Treatment.) 

The  next  published  recognition  of  the  possibility  of  reducing  a  dis- 
location of  the  hip  by  manipulation  alone  was  by  Despres,  who,  in  1835, 
communicated  to  the  Societe  Anatomique  of  Paris ^  "a  new  method  of 
reducing  dislocations  of  the  fenuir"  by  flexion  and  rotation  outward. 
The  only  comment  it  excited  at  the  time,  according  to  the  records  of 
the  society,  was  the  mention  a  few  months  later  by  Pign6  of  the  fact 
that  the  same  nu^thod  was  described  by  Beach  in  a  Treatise  on  Medi- 
cine, published  in  New  York  in  1833,  and  was  there  said,  on  the 
authority  of  Sweet,  the  "  natural  bone-setter,"  to  have  been  practised 
by  the  savages  of  North  America."     The  Despres  incident  is  mainly 

'  Despris:  BiiU.  de  la  Soc.  Anatoiuique,  Se])tciii1)er,  ISo.",  p.  4. 

■^  Ijiacli.  likf  Sweet,  appears  to  liave  been  an  irregular  in'actitioiier,  and  it  is  likely  tliat 
his  assertions,  even  when  known,  were  not  deemed  wortliy  of  serious  consideration. 

37 


522  DISLOCATIONS. 

noteworthy  as  showing  how  completely  the  previous  suggestions  had 
been  forgotten  or  overlooked,  even  by  Pouteau's  own  countrymen.  It 
is  now  used  by  the  French  as  a  justification  for  speaking  of  the  method 
by  manipulation  (at  the  hip)  as  the  "  Methode  de  Despres^ 

In  like  manner,  other  surgeons  sought  to  modify  the  practice  as 
regarded  tlie  shoulder-joint,  by  advising  that  the  traction  should  be 
made  in  different  directions  and  combined  with  rotation  of  the  limb. 
Of  these  the  most  noteworthy  are  Mothe  and  Lacour,  since  it  is  with 
their  practice  that  the  manipulative  methods  are  generally  thought  to 
have  begun. 

The  earlier  manipulative  methods  were  either  empirical  or  based 
upon  more  or  less  incorrect  notions  of  the  nature  of  the  obstacles  to  be 
overcome  and  of  the  mechanism  by  which  the  result  was  to  be  obtained, 
and  it  is  only  since  the  pathology  of  the  different  dislocations  has  been 
better  understood,  with  reference  especially  to  the  position  of  the  rent 
in  the  capsule  and  the  influence  of  the  portions  which  remain  untorn, 
that  the  different  procedures  embraced  under  this  method  have  been 
intelligently  devised  and  executed.  They  differ  so  widely  in  their 
details  that  only  the  most  general  description  can  be  given  here  ;  they 
consist  in  giving  to  the  limb  successive  positions,  by  which  the  head  of 
the  bone  is  first  brought  opposite  the  opening  in  the  capsule  and  then 
into  its  cavity,  and  by  which  the  opening  in  the  capsule  is  made  to 
gape  widely,  or  is  actually  enlarged  if  necessary.  For  the  accomplish- 
ment of  these  ends  the  limb  is  used  as  a  means  of  acting  upon  the  cap- 
sule so  far  as  it  remains  attached  to  the  bone,  and  the  head  of  the  bone 
is  made  to  take  its  successive  positions  by  rotation  of  its  shaft,  or  by 
using  it  as  a  lever  which  finds  its  fixed  point  either  upon  some  adjoin- 
ing prominence  of  bone  or  in  the  capsule,  or  by  moving  the  entire  limb 
in  the  direction  of  its  long  axis.  Combined  with  these  manipulations 
it  is  commonly  necessary  to  employ  a  certain  amount  of  traction  to  Over- 
come gravity  or  such  resistance  as  is  offered  by  the  muscles. 

It  rests  essentially  upon  an  anatomical  and  pathological  basis  con- 
sisting of  two  parts,  the  position  of  the  rent  in  the  capsule  and  the 
resistance  of  tlie  untorn  portion,  and  depends  for  its  lyiowledge  of  these 
two  factors,  in  any  given  case,  mainly  upon  the  position  occupied  by 
the  limb  and  the  limitations  of  the  movements.  Resistance  of  the 
muscles,  when  present,  is  overcome  by  anaesthesia  or  by  traction. 

Such  traction  as  is  required  is  made  by  the  hands  of  the  surgeon  or 
of  an  assistant,  or  by  the  weight  of  the  dependent  limb,  or  by  the  pro- 
longed action  of  an  elastic  band  or  of  a  weight  suspended  over  a  pulley. 

Continuous  traction  by  India-ritbber-  bands  was  introduced  by  Legros 
and  Onimus  while  internes  in  the  Paris  hospitals,  1863  to  1866,  and 
advocated  by  them  in  a  paper  published  in  1868.'  They  recognized 
that  their  object,  the  fatigue  of  the  opposing  muscles,  could  be  equally 
well  accomplished  by  weight  and  pulley  or  a  steel  spring,  but  they  gave 
the  preference  to  India-rubber  because  of  the  ease  with  which  it  could  be 
used.     Their  reported  cases  are  dislocations  of  the  shoulder  and  elbow. 

The  method  of  application  in  dislocations  forward  of  the^  shoulder, 

'  Legros  and  Onimus:  Des  Tractions  continues,  et  de  leur  Application  en  Cbirurgie. 
Arch.  Generales  de  Med.,  January,  1868. 


TREATMENT.  523 

for  example,  is  as  follows  :  A  loop  is  made  fast  to  the  lower  part  of  the 
arm  by  turns  of  a  roller-bandage  or  by  strips  of  adhesive  plaster  as  in 
Buck's  extension  ;  then  the  patient  is  seated  in  a  chair,  counter-exten- 
sion provided  by  a  band  passing  around  the  chest  under  the  axilla  and 
over  the  opposite  shoulder  and  made  fast  to  some  neighboring  fixed 
point,  the  elbow  gently  raised  to  or  nearly  to  the  position  of  horizontal 
abduction,  and  traction  made  in  the  direction  of  its  long  axis  by  a 
rubber  cord  passed  through  the  loop  attached  to  the  arm  and  around  a 
fixed  point  established  in  an  appropriate  position.  The  traction  should 
be  about  twenty  or  twenty-live  pounds,  and  needs  to  be  continued  for 
from  fifteen  to  thirty  minutes  ;  under  its  influence  the  muscles  become 
relaxed  and  the  patient  experiences  the  sensation  of  great  fatigue,  the 
lie^d  of  the  bone  gradually  a})proaches  the  glenoid  cavity,  and  either 
enters  it  spontaneously  or  is  replaced  by  the  pressure  of  the  surgeon's 
fingers,  or  by  a  sudden  pull  upon  the  arm. 

Continuous  traction  by  the  weight  of  the  limb  is  used  at  the  hip  and 
shoulder.  The  limb  is  placed  in  such  a  position  that  its  weight  tends 
to  move  it  in  the  desired  direction  ;  thus  the  thigh  is  allowed  to  hang 
down  (the  knee  flexed  and  the  leg  horizontal)  at  the  end  of  a  table 
upon  which  the  body  of  the  patient  lies  prone.  For  the  shoulder,  the 
patient  is  placed  upon  his  side  on  a  cot  through  a  hole  in  which  the 
injured  arm  hangs  directly  down.  To  the  weight  of  the  limb  in 
either  case  that  of  a  sand  bag  may  advantageously  be  added.  (See 
Chapters  XLII.  and  LI.) 

Athrotomy.  Occasionally  a  fresh  dislocation  is  irreducible  becau.se 
of  an  exceptional  position  of  the  bones  or  of  interposition  of  the  soft 
parts.  I  have  seen  this  once  each  at  the  shoulder,  elbow,  and  temporo- 
maxillary  joints,  and  a  nuiiiber  of  times  at  the  metacarpo-phalangeal 
joints  and  in  dislocations  with  fracture.  At  the  shoulder  the  head  of 
the  humerus  had  passed  below  and  then  so  far  to  the  inner  side  of  the 
subscapularis  that  its  tendon  was  closely  wrapped  about  the  outer  side 
of  the  neck  of  the  bone  and  had  to  be  divided  ;  at  the  elbow,  apjiarently 
in  consequence  of  repeated  attempts  to  reduce,  the  denuded  end  of  the 
humerus  had  been  forced  through  the  fascia  in  the  flexure  of  the  joint, 
and  the  tendon  of  the  biceps  was  lodged  behind  the  external  condyle  ; 
at  the  jaw,  the  meniscus  had  been  torn  away  from  the  condyle  and  was 
lodged  behind  it. 

If  such  an  operation  is  done  within  a  day  or  two  after  the  accident 
the  risk  is  no  more  than  that  of  a  similar  opening  of  the  unlaccrated 
joint;  but  while  inflammatory  reaction  is  active  and  oedema  is  marked 
the  chance  of  suppuration  is  greater,  and  it  is  then  well,  I  think,  to 
await  their  subsidence  before  operating. 

Old  Unreduced  Dislocations. 

The  changes,  above  described,  which  take  ])lace  about  a  dislocated 
bone  gradually  increase  the  difficulty  of  redu(^tion  by  means  that  are 
sufficient  while  the  dislocation  is  fresh,  and  ultimately  make  it  im])()s- 
sible.  The  conditions  vary  so  greatly  with  individual  cases  and  with 
the  different  joints,  and  their  extent  and  detail  are   so  unrecognizable 


524  DISLOCATIONS. 

clinically  and  so  largely  a  matter  of  inference  that  the  difficulty  cannot 
be  measured  simply  by  the  length  of  time  that  has  elapsed,  and  too 
often  not  ev^en  by  anything  short  of  an  actual  trial. 

The  common  practice,  until  within  quite  recent  times,  was  simply  to 
employ  the  usual  forcible  means  more  forcibly,  to  rupture  adhesions  by 
forcing  the  limb  in  various  directions,  and  then  to  drag  it  into  place  by 
pulleys  or  specially  devised  apparatus.  While  this  succeeded  in  many 
cases,  and  even  occasionally  in  some  at  the  shoulder  and  hip  which  had 
existed  for  months,  yet  the  record  is  full  of  accidents  and  disasters, 
and  many  a  grave  warning  has  been  uttered  against  the  dangers  of  the 
attempt  even  in  apparently  suitable  cases  and  against  the  temptation  to 
subordinate  the  patient's  welfare  to  a  desire  to  obtain  an  unusual  success. 

The  dangers  of  forcible  reduction  in  cases  of  long  standing,  and  the 
superiority  of  operative  methods  to  meet  the  special  indications  that 
may  exist  in  them,  are  now  so  well  understood  that  the  warning  is  not 
much  needed  in  such  cases ;  it  is  in  the  more  recent  cases,  those  of  a 
few  weeks,  that  it  is  now  specially  necessary  to  be  on  guard  against 
being  unwittingly  led  to  strive  too  long,  to  make  a  stronger  and  still  a 
stronger  pull  after  less  force  has  failed.  The  danger  is  specially  great 
in  the  old,  whose  diseased  arteries  may  so  easily  be  bruised  or  torn, 
and  whose  thinned  bones  may  so  easily  be  broken.  The  following 
two  cases  which  recently  occurred  in  the  service  of  a  surgeon  in  a 
prominent  New  York  hospital,  within  a  year  of  each  other  (1896—97), 
illustrate  the  temptation  and  the  risk. 

A  woman  sixty-seven  years  old  ;  subcoracoid  dislocation  two  weeks 
old.  Ether ;  traction  by  pulleys,  estimated  at  300  pounds ;  reduction 
on  second  attempt.  The  following  day  the  radial  pulse  could  not  be 
felt,  and  gangrene  deemed  imminent ;  seven  weeks  later  amputation  of 
the  arm ;  death.  The  autopsy  showed  a  thrombus  in  the  brachial 
artery. 

Man  sixty-eight  years  old ;  subcoracoid  dislocation  six  weeks  old. 
Ether ;  manipulation  to  rupture  adhesions ;  Kocher's  method  tried 
twice,  then  heel  in  the  axilla.  Then  arm  carried  forcibly  across  the 
body,  the  head  slipping  to  the  outer  side  of  the  glenoid  fossa;  finally 
traction  in  abduction  succeeded.  Died  five  hours  later.  Autopsy 
showed  rupture  of  the  axillary  vein  and  of  the  short  head  of  the 
biceps ;  capsule  entirely  torn  from  the  humerus ;  third,  fourth,  and 
fifth  ribs  fractured  in  the  axillary  line. 

The  alternative  measui'es — reduction  by  operation,  excision,  and 
osteotomy — have  been  made  so  much  safer  than  formerly  by  improved 
surgical  technique  that  they  are  now  resorted  to  with  increasing  fre- 
quency, and  the  resulting  experience  has  been  such  that  rules  of  treat- 
ment can  be  formulated  for  some  of  the  joints.  In  backward  dislocation 
of  the  elbow  formal  exposure  by  two  lateral  incisions  and  removal  of 
the  cicatricial  tissue  permit  complete  reduction  and  usually  a  notable 
improvement  of  function.  At  the  shoulder  the  range  of  motion  after 
reduction  by  operation  has  generally  been  small,  and  the  operative 
difficulties  are  often  great,  but  Prof.  Dollinger's  method  by  division  of 
the  tendon  of  the  subscapularis  has  made  it  relatively  easy  and  safe  in 
a  large  proportion  of  cases;  excision  of  the  head  is  sometimes  required 


TREAtMEifT.  525 

as  an  alternative,  and  occasionally  osteotomy,  merely  to  improve  the 
attitude  of  the  limb.  At  the  hij)  reduction  by  operation  has  ])roved 
dangerous  and  has  failed  in  more  than  half  the  trials ;  even  Avhen  it 
has  succeeded  the  functional  gain  has  not  often  been  notable,  but  here, 
too,  Prof.  Dollinger  has  added  to  our  knowledge  and  systematized  a 
method  which  may  well  yield  better  results.     (See  Chapter  LIII.) 

The  facts  and  general  principles  to  be  considered  in  determining 
upon  resort  to  operative  interference  and  in  making  a  choice  of  methods 
are  as  follows  : 

1.  At  the  present  time  wound  infection  is  of  more  frequent  occur- 
rence after  operative  reduction  of  old  dislocations  of  the  large  joints 
than  in  other  primarily  clean  operations,  and  an  almost  inevitable 
result  of  such  infection  is  anchylosis  of  the  joint ;  and  even  in  cases 
which  escape  infection  the  restoration  of  function  is  quite  incomplete. 
Consequently,  the  usefulness  of  the  limb  in  the  existing  conditions  and 
the  probable  gain  by  interference  should  be  carefully  considered. 

2.  A  faulty  fixed  position  may  be  so  im])roved  by  an  operation  that 
the  usefulness  will  be  increased  even  if  anchylosis  follows. 

3.  On  the  other  hand,  and  this  is  specially  true  of  the  hip,  the  im- 
provement to  be  got  by  a  change  of  position  may  be  far  too  slight  to 
justify  the  risks  of  an  operation  so  extensive  as  would  be  required  for 
reduction,  and  an  almost  equal  improvement  might  be  had  by  an  oste- 
otomy. 

4.  Pain  and  trophic  changes  in  the  limb  due  to  pressure  upon  nerves 
are  good  reasons  for  interference ;  the  relief  would  probably  be  more 
surely  and  easily  obtained  by  an  excision  of  the  head  of  the  bone. 

5.  Excision,  when  undertaken  only  to  improve  function,  is  suitable 
at  the  shoulder  and  elbow,  but  must  be  sparingly  employed  at  the  hip 
where  solidity  of  support  is  more  important  than  mobility. 

After-treatment. 

After  a  dislocation  has  been  reduced,  there  is  needed,  in  most  cases, 
only  a  simple  retention  bandage  to  confine  the  limb  in  an  easy  position, 
but  in  some  cases — dislocation  of  either  end  of  the  clavicle,  of  the 
head  of  the  radius,  and  sometimes  of  the  shoulder  backward  under 
the  spine  of  the  scapula  (Busch  and  Kronlein) — the  tendency  to  recur- 
rence is  so  great  that  special  dressings  are  required.  The  joint  should 
be  kept  quiet,  certainly  any  movement  that  causes  pain  should  be 
avoided,  and  if  the  inflammatory  reaction  threatens  to  be  severe  it 
must  be  opposed  by  the  application  of  cold,  or  uniform  gentle  press- 
ure if  it  can  be  borne.  After  a  week  or  two  the  use  of  the  limb  may 
be  gradually  resumed.  In  making  passive  motion  or  this  use  of  the 
limb,  those  positions  must  be  avoided  in  which  the  head  of  the  bone 
would  press  upon  the  torn  part  of  the  capsule,  or  in  which  the  sides 
of  the  rent  would  be  again  separated  from  each  other. 

If,  as  sometimes  happens,  the  joint  remains  stiff,  weak,  and  sensitive, 
but  is  cold  rather  than  warm,  and  aches  and  jierhaps  becomes  puffy 
after  use,  it  needs  massage  and   rubbing,  and   to  be  actively  moved 

'  For  many  cases  of  various  forms  of  operation  see  Eugel,  in  Arch,  fiir  klin.  Chir., 
1897,  vol.  Iv.  p.  603. 


526  DISL  0  CA  TIONS. 

either  by  the  patient  or  l)y  the  physician.  Its  sensitiveness  and  immo- 
bility under  such  circumstances  are  due  to  the  prolonged  disuse,  to 
retraction  and  loss  of  pliability  in  the  peri-articular  tissues,  and  possibly 
to  the  presence  of  adhesions  within  the  cavity  itself. 

Habitual  Dislocation. 

A  marked  tendency  to  recurrence  may  be  combated  by  prolonged 
immobilization  of  the  joint  if  the  injury  is  comparatively  recent,  or 
by  special  treatment  designed  to  thicken  and  shorten  the  capsular  and 
peri-articular  tissues.  Geuzmer^  successfully  employed  in  two  cases  of 
recurrent  dislocation  of  the  shoulder  repeated  injections  into  the  joint 
of  the  pure  tincture  of  iodine.  The  needle  was  introduced  a  finger- 
breadth  below  the  coracoid  process,  and  seven  to  ten  minims  were  in- 
jected. The  arm  was  then  immobilized,  and  the  injections  repeated 
from  five  to  seven  times  at  intervals  of  three  or  four  days.  He 
recommended  the  same  treatment  for  habitual  dislocation  of  the 
lower  jaw. 

DubreuiP  reports  a  cure  at  the  shoulder  by  six  injections,  during  a 
fortnight,  of  two  drops  each  of  a  10  per  cent,  solution  of  chloride  of 
zinc  into  the  peri-articular  tissues.  At  the  sternal  end  of  the  clavicle 
I  have  twice  obtained  a  good  result  by  injecting  a  few  drops  of  alcohol 
into  the  peri-articular  tissues  and  immobilizing  for  a  fortnight. 

An  operative  method  which  has  proved  c,afe  and  efficient  at  the 
shoulder  is  one  introduced  by  Ricard,^  the  formation  of  a  permanent 
fold  in  the  anterior  portion  of  the  capsule  by  three  vertical  silk  sutures. 
A  similar  method  has  been  used  in  habitual  outward  dislocation  of  the 
patella.     See  also  Chapter  XLIV. 

1  Genzmer:  Centralblatt  fur  Chirurgie,  1883,  p.  563. 

2  Dubreuil :  La  Semaine  Med.,  February  27,  1892. 
'^  Ricard  :  Acad,  de  Med.,  October  31,  1892. 


CHAPTEE   XXXIV. 

ACCIDENTS   THAT   MAY   BE  CAUSED  BY  ATTEMPTS  TO  EEDUCE 

A  DISLOCATION. 

The  complications  or  accidents  that  may  be  caused  by  the  attempt 
to  reduce  a  dislocation  may  appear  during  the  attempt,  as  the  imme- 
diate consequence  of  the  manoeuvres  emjiloyed,  or  subsequently  as  a 
more  or  less  remote  consequence  of  the  changed  conditions,  the  local 
injuries,  or  the  inflammation  produced  by  those  manoeuvres ;  and  they 
may  be  localized  at  or  near  the  dislocated  joint,  or  may  be  the  result  of 
a  local  distant  change  or  of  a  more  diffused  impression  upon  the  organ- 
ism. They  may,  therefore,  be  grouped  as  :  1  st,  primary  local  accidents  ; 
2d,  consecutive  local  accidents  ;  3d,  cases  of  hemiplegia,  syncope,  and 
sudden  death.  The  first  group  comprises  injuries  of  the  skin,  cellular 
tissues,  muscles,  vessels,  nerves,  and  bones ;  the  second  group  includes 
suppuration  in  or  about  the  joint,  and  oedema,  gangrene,  and  paralysis 
consequent  to  injury  to  vessels  or  ners'es.  The  third  group  includes 
those  cases  of  shock  or  exhaustion,  sometimes  proving  fatal,  which 
have  become  exceedingly  rare  since  the  introduction  of  ansesthetics, 
and  those  others,  that  have  come  in  their  place,  of  death  due  to  the 
ansesthetic  itself. 

It  is  noticeable,  on  comparison  of  the  cases  that  have  occurred  at 
different  periods,  that  while  some  varieties  of  the  lesions  are  common 
to  all  times,  with  their  varying  methods  of  treatment,  others  are  in  a 
manner  dependent  upon  the  means  by  which  the  reduction  has  been 
attempted.  Thus,  violent  traction  is  the  sole  cause  of  some ;  manoeu- 
vres, such  as  abduction  and  rotation  of  the  arm,  the  principal  cause  of 
others  ;  violent  pressure  at  or  near  the  head  of  tlie  bone,  prolongation 
of  the  effort,  and  ansesthetics,  each  of  its  own  peculiar  varieties.  Not- 
withstanding these  differences,  certain  points  may  be  recognized  as 
common  to  the  greater  number,  such  as  the  age  of  the  patient  and  the 
length  of  time  during  which  the  dislocation  has  remained  unreduced. 
Injuries  of  the  vessels  have  been  most  frequent  in  the  old  and  in  dis- 
locations of  long  standing,  and  all  the  other  accidents  have,  in  recent 
times  at  least,  been  rarely  seen  except  in  connection  with  dislocations 
that  have  long  remained  unreduced  or  that  have  been  complicated  by 
much  inflammatory  reaction.  The  reasons  for  the  greater  liability  to 
rupture  of  the  arteries  under  these  conditions  are  not  obscure;  the  loss 
of  elasticity  because  of  atheromatous  change  in  the  vessels  in  the  old, 
and  the  adhesion  of  the  vessels  to  adjoining  jiarts  as  a  sequence  of 
inflammation  are  a  sufficient  explanation,  and  the  mechanical  difficul- 
ties created  by  the  contraction  and  readjustment  of  the  torn  tissues  in 
old  dislocations  explain  the  others  by  the  force  that  is  required  to  over- 
come them. 

( 527  ) 


528  DISLOCATIONS. 

Integument.  The  skin  may  be  bruised  or  lacerated  at  a  distance  from 
the  joint  by  the  pressure  of  the  cords  through  which  traction  is  made, 
or  near  the  joint  by  the  pressure  of  the  hands  or  instruments  acting 
upon  the  dishx-ated  end  of  the  bone,  or  it  may  be  torn  across  if  the 
traction  is  exerted  upon  it  rather  than  upon  the  bone.  These  lesions 
are  seldom  serious,  and  the  former  may  usually  be  avoided  by  protect- 
ing the  surface  with  thick  layers  of  cotton  or  flannel.  Transverse 
rupture  of  the  skin  between  the  points  of  extension  and  counter-exten- 
sion is  due  to  a  faulty  application  of  the  force,  by  which  it  is  exerted 
upon  the  skin  alone  and  not  upon  the  underlying  bone.  The  skin  is 
elastic  and  tough,  and  when  unaltered  by  disease  will  support  a  very 
considerable  strain,  one  far  in  excess  of  that  commonly  needed  to  over- 
come the  contraction  of  a  muscle,  but  the  traction  may  be  so  applied 
that  it  will  act  only  upon  the  skin.  Thus,  if  a  broad  band  is  strapped 
snugly  about  the  middle  of  the  arm  and  traction  is  made  by  a  cord 
attached  to  it,  it  will  draw  the  skin  downward  toward  the  elbow  ;  and 
if  at  the  same  time  the  skin  of  the  axilla  and  chest-wall  is  prevented 
by  counter-extension  from  sharing  in  the  movement,  the  intermediate 
portion  is  put  upon  the  stretch  and  may  tear. 

To  guard  against  the  occurrence  of  this  accident  the  limb  should  be 
firmly  grasped,  if  traction  by  the  hands  is  used,  at  the  enlarged  distal 
end  of  the  bone,  so  that  the  skin  should  not  be  drawn  downward  by 
the  slipping  of  the  hands,  and  the  additional  precaution  may  be  taken 
to  press  the  skin  of  the  forearm  (in  the  case  of  a  shoulder  dislocation) 
upward  before  the  limb  is  grasped,  and  similar  precautions  suitable  to 
the  region  should  be  taken  at  the  point  of  counter-extension.  If  trac- 
tion is  made  by  a  cord  or  band,  it  should  be  attached  to  the  limb  just 
above  a  bony  prominence  or  enlargement  which  will  prevent  its  slip- 
ping ;  it  should  not  be  made  fast  simply  by  enclosing  its  loop  in 
circular  turns  of  a  bandage  which  maintain  their  hold  upon  the  skin 
by  friction. 

Sloughing  of  the  skin,  due  to  its  compression  against  an  underlying 

bone  by  direct  pressure  exerted  to  force  the  latter  back  into  place,  has 

been  occasionally  observed,  in  a  dislocation  of  the  astragalus,^  and  over 

the  olecranon  in  an  attempt  made  by  a  bonesetter  to  reduce  a  backward 

'  dislocation  of  the  elbow. 

Emphysema  of  the  Cellular  Tissue.  This  has  been  noted  in  one 
case.  Flaubert^  reduced  a  dislocation  of  the  shoulder  of  five  weeks' 
standing  in  a  woman  seventy  years  old  ;  the  first  attempt  was  unsuc- 
cessful ;  in  the  second  traction  was  made  by  eight  students,  and  the 
patient,  who  at  first  uttered  vehement  cries,  seemed  afterward  to  be 
upon  the  point  of  suffocating,  and  her  face  became  purple  and  injected. 
An  emphysema  immediately  appeared  above  the  clavicle  and  spread 
over  the  shoulder  to  the  middle  of  the  back.  She  died  on  the 
eighteenth  day,  apparently  in  consequence  of  the  tearing  away  of  the 
lower  four  trunks  of  the  brachial  plexus  at  their  attachment  to  the 
spinal  cord. 

'  Dauvc :  Eec.  de  Mem.  de  Med.  et  Chir.  Milit.,  1867,  vol.  xix.  p.  143. 
^  Flaubert:  Repertoire  d'Anat.  et  de  Phys.,  1827,  quoted  by  Malgaigne. 


ACCIDENTS  BY  ATTEMPTS  TO  REDUCE  A  DISLOCATION.    529 

Rupture  of  the  Muscles.  Under  this  head  only  those  lacerations 
of  the  muscles  will  be  mentioned  which  are  occasioned,  especially  in  old 
dislocations,  by  yiolent  traction  or  by  forcible,  exaggerated,  and  long- 
continued  manipulation  of  the  limb.  The  cases  in  which  the  injury 
has  been  confirmed  by  autopsy  are  few,  only  those  in  A\hich  death  has 
promptly  followed  in  consequence  of  associated  lesions  or  of  the  inflam- 
mation to  which  the  violence  has  giyen  rise.  Yet,  in  another  of  Flau- 
bert's cases,'  there  seems  to  be  no  doubt  that  not  only  the  muscles  but 
also  the  ligaments  and  other  soft  parts  were  extensively  torn.  The 
case  was  one  of  dislocation  of  the  elbow  backward,  twenty-seven  days 
old,  in  which  traction  was  made  upon  the  forearm  by  seven  assistants ; 
suddenly  the  parts  seemed  to  yield  and  change  their  positions  with  a 
sound  of  tearing,  and  at  the  same  moment  a  zone  of  narrowing  or 
depression  appeared  at  the  level  of  the  joint  with  a  bony  prominence 
above  and  below.  It  seemed  to  all  present  that  the  muscles  and  soft 
parts  covering  the  joint  had  been  ruptured,  leaving  a  gap  two  inches 
long.  „An  enormous  fluctuating  swelling  promptly  appeared,  the  radial 
pulse  returned  the  next  day,  and  the  patient  recovered. 

In  the  cases  confirmed  by  autopsy  the  dislocation  has  always  been 
of  the  shoulder,  and  the  muscles  most  frequently  torn  have  been  the 
pectoralis  major  and  the  subscapularis. 

Avulsion  of  a  portion  of  a  limb  is  fortunately  a  very  rare  accident. 
Except  for  one  or  two  cases  of  avulsion  of  the  thumb,  known  only  by 
tradition,  the  only  instance  of  complete  avulsion  is  that  in  which 
Alphonse  Guerin  tors  away  the  forearm  at  the  elbow  in  an  attempt  to 
reduce  a  subcoracoid  dislocation  of  the  shoulder  of  six  weeks'  standing.^ 

The  rupture  took  place  mainly  through  the  joint,  a  small  portion  of 
each  condyle  remaining  attached  to  the  muscles  of  the  forearm,  and  a 
portion  of  the  olecranon  to  the  triceps.  The  muscles  M^ere  softened 
and  brown  ;  the  nerves  were  injected,  with  nodes  at  intervals  ;  the  veins 
were  dilated.  The  ends  of  the  long  bones  were  profoundly  disorgan- 
ized, with  thinning  of  the  compact  shell  and  rarefaction  of  the  spongy 
part ;  they  broke  under  slight  pressure  and  could  be  easily  perforated 
with  the  scalpel.  Microscopical  examination  showed  degeneration  of 
the  nerves,  muscles,  and  bones. 

The  patient  died  on  the  thirteenth  day,  and  the  autopsy  showed  no 
change  in  the  tissues  of  the  other  limbs ;  the  muscles  of  the  shoulder 
were  normal,  except  the  deltoid,  the  fibres  of  which  were  pale  and 
degenerated.  The  nerves  w^ere  matted  together  in  the  axilla  and  firmly 
pressed  against  the  head  of  the  humerus  ;  above  the  point  of  compres- 
sion they  were  normal,  contrasting  strongly  with  the  parts  below. 

It  is  evident  that  the  accident  was  favored  by  great  trophic  changes 
in  the  limb,  probably  due  to  pressure  upon  the  nerves  in  the  axilla. 

Injuries  of  the  Main  Bloodvessels.^  Although  the  earliest  recorded 
cases  of  accidents  of  this  class  occurred  at  about  the  beginning  of  the 
eighteenth  century,  the  subject  did   not  receive  the  attention   of  sys- 

1  Malgaigne  :  Loc.  cit.,  p.  149.       ^  Gueriii :  Bull,  de  la  Soc.  de  Chir.,  18f)4,  pp.  121  and  1.'51. 
'  See  also  an  elaborate  article  by  Guibc,  giving  49  cases  in  Revue  de  Chir.,  1911,  vol. 
xliv.  p.  .581. 


530  DISLOCATIONS. 

teraatic  writers  on  surgery  until  after  the  publication,  in  1827,  of  an 
article  by  Flaubert/  Malgaigne,  in  1855,  discussed  the  subject  at 
length  in  his  work  on  dislocations,  mentioning  sixteen  cases  of  all 
kinds,  certain  and  uncertain.  Callender,"  taking  as  a  text  his  own 
fatal  case,  again  collected  and  collated  the  known  cases ;  and  similar 
use  was  made  of  the  material  and  other  cases  added  to  the  list  by  Le 
Fort,-^  Willard,-'  and  Marchand.^  In  1882  Korte '^  reported  three' per- 
sonal cases,  and  wrote  a  very  full  and  valuable  paper  on  the  subject, 
containing  forty-four  supposed  (actually  thirty  eight;  see  first  edition, 
p.  79)  cases  of  dislocation  of  the  shoulder  in  which  the  vessels  had  been 
seriously  injured  during  the  act  of  dislocation  or  of  reduction;  and  in 
1884  Cras''  reported  a  personal  case  of  injury  of  the  axillary  artery, 
and  added  a  few  others  to  Kdrte's  list.  Strictly  speakiug,  several  of 
these  cases  should  not  be  here  considered,  since  in  them  the  vessel  was 
injured  at  the  moment  of  dislocation  and  not  during  reduction,  and  in 
many  others  it  remains  uncertain  whether  the  same  objection  might  not 
be  made  to  them.  They  are  retained  because  they  serve  equally  well 
with  the  others  to  further  the  study  of  most  features  of  the  subject. 

I  have  met  with  only  two  recorded  cases  in  which  a  large  bloodvessel 
has  been  injured  in  the  reduction  of  any  dislocation  except  of  the 
shoulder.  These  were  both  of  the  elbow,  the  cases  of  Flaubert  and 
Michaux,  (pioted  by  Marchand  and  Malgaigne.  The  former  has  been 
already  quoted  under  rupture  of  the  muscles ;  in  the  latter  the  patient 
was  ten  years  old,  and  the  dislocation  was  of  the  elbow  backward  and 
outward,  the  swelling  was  considerable,  the  radial  pulse  was  present. 
Reduction  was  attempted  on  the  day  after  the  accident,  and  on  the 
next  following  day,  but  without  success.  The  last  attempt  was  imme- 
diately followed  by  swelling  of  the  elbow  and  by  arrest  of  pulsation  in 
the  radial  and  ulnar  arteries ;  gangrene  set  in,  and  six  days  after  the 
attempt  the  limb  was  amputated.  The  tendons  of  the  biceps  and 
brachialis  anticus  were  found  to  have  been  forced  by  the  mani[)ulation 
around  the  external  condyle  to  the  posterior  aspect  of  the  humerus, 
accompanied  by  the  ruptured  brachial  artery  and  median  nerve. 

In  1885  I**  found  forty-seven  trustworthy  accounts  of  injury  to  the 
larger  vessels  of  the  axilla  in  dislocation  or  reduction  of  dislocation  of 
the  shoulder.  Since  then  Caldwell  ^  has  reported  a  case  thought  to  be 
rupture  of  the  anterior  circumflex  artery,  and  I  have  learnedof  one  of 
rupture  of  the  axillary  vein  (Weir).  The  latter  has  been  quoted  above 
(p.  446).  Caldwell's  patient  was  fifty-eight  years  old,  and  the  disloca- 
tion had  been  promptly  reduced.  Six  weeks  later  "there  was  a  large 
fluctuating  swelling  in  the  outer  aspect  of  the  shoulder,  over  the  area 
covered  by  the  deltoid  ; "  pulsation  at  wrist  and  in  axillary  artery  ;  no 

1  Flaubert :  Mem.  sur  plusieurs  cas  de  luxations  dans  lesquels  les  efforts  pour  la  reduc- 
tion ont  ete  suivis  d'accidents  graves,  Repertoire  d'anat.  et  de  phys.,  1827. 

2  Callender:  St.  Bartholomew's  Hospital  Reports,  1866,  vol.  ii.  p.  96. 
^  Le  Fort:  Diet,  encvclopedique  des  sci.  med.,  article  Axillaires. 

*  Willard  :  Philadelphia  Medical  Times,  1873,  vol.  iii.  p.  721. 

^  Marchand  :  Des  accidents  qui  peuvent  compliquer  la  reduction  des  luxations  traumat- 
iqoes.  These  de  concours,  Paris,  1875. 

^  Korte  (first  paper) :  Arch,  fiir  klinische  Chirurgie,  vol.  xxvii.  p.  631. 
7  Cras :  Bull,  de  la  Societe  de  Chirurgie,  1884,  p.  739. 

*  Stimson:  New  York  Medical  Journal,  June  13,  1884,  and  first  edition  of  this  work. 
9  Caldwell :  Cincinnati  Lancet-Clinic,  May  3,  1890. 


ACCIDENTS  BY  ATTEMPTS  TO  REDUCE  A   DISLOCATION.    531 

swelling  in  axilla.  Under  the  impression  that  the  swellino;  was  due  to 
an  abscess  an  incision  Avas  made  and  about  a  pint  of  clotted  blood  evacu- 
ated ;  this  was  followed  by  arterial  hemoi-rhage,  arrested  by  pressure  of 
the  thumbs  in  the  wound.  The  wound  was  enlarged,  but  the  source  of 
the  bleeding  was  not  found.  Tlie  wound  was  packed  with  gauze,  and 
the  patient  recovered.  In  1901  Korte'  reported  another  personal  case 
and  collected  five  not  included  among  those  already  mentioned,  and  in 
1905  Hessmann^  one  of  rupture  of  the  axillary  artery,  in  a  man  sev- 
enty-two years  old.  He  ligated  the  subclavian  artery,  and  a  fortnight 
later  disarticulated  the  limb.     Recovery. 

Of  these,  the  axillary  vein  alone  was  ruptured  in  four  (Froriep,  Price, 
Weir,  Hailey),  although  I  think  the  last  one  doubtful,  and  the  artery 
and  vein  together  in  three  (Platner,  Baum,  Sonnenburg)."*  In  most  of 
the  others  the  axillary  artery  or  one  of  its  branches  was  injured,  but 
in  some  the  source  of  the  hemorrhage  remains  uncertain.  In  thirty- 
live  cases  death  or  amputation  of  the  arm  furnished  the  opportunity 
to  examine  the  region  and  determine  the  character  of  the  lesion  ; 
this,  in  some  cases,  was  a  complete  or  partial  rupture  of  all  the  coats 
of  the  artery  or  of  the  inner  and  middle  coats  alone,  with  subse- 
quent formation  of  a  circumscribed  aneurism.  In  other  cases  the 
vitality  of  the  wall  appears  to  have  been  diminished  or  destroyed  by 
direct  pressure,  and  this  to  have  been  followed,  after  the  lapse  of  a 
few  days,  by  rupture,  or,  still  later,  by  the  formation  of  an  aneurism. 
In  Gibson's  second  case  an  aneurism  ap])ears  to  have  formed  in  conse- 
quence of  the  earlier  attempts  to  reduce,  and  then  itself  to  have  been 
ruptured  when  Gibson  effected  re-duction.  Rupture  always  appears  to 
have  taken  place  quite  high  up,  and  usually  at  the  point  pressed  upon 
by  the  head  of  the  humerus.  Callender  found  it  necessary  to  divide 
the  pectoralis  minor  to  reach  it.  In  the  fatal  cases  of  injury  of  the 
vein  alone  the  vessel  was  torn  completely,  or  almost  completely,  across. 

In  seven  cases  only  a  small  (one-sixth  of  an  inch)  oval  opening  was 
found  on  the  anterior  wall  of  the  artery,  and  was  thought  to  have  been 
produced  by  the  tearing  off  of  a  branch,  the  subscapular  or  circumflex. 

In  other  cases  the  subscapular  or  the  circumflex  artery  was  torn 
across  at  or  near  its  origin.  The  cases  of  this  kind  form  a  consider- 
able proportion  of  the  whole  number,  and  are  of  great  importance 
because  they  ex])lain  the  persistence  of  the  radial  pulse  noted  in  several 
of  the  histories.  In  Parker's  the  swelling  was  at  the  axillary  border 
of  the  scapula  behind,  "  near  the  situation  of  the  dorsal  scapular  artery 
or  the  subscapular  at  the  junction  of  the  two  ;  "  in  Caldwell's  under  the 
deltoid. 

Of  thirty-four  cases  in  which  the  age  of  the  patients  is  given,  in 
twenty-two  they  were  more  than  forty  years  old.  The  youngest  was 
twenty,  the  oldest  eighty-six.  In  very  few  of  the  cases  it  is  noted  that 
the  arteries  were  atheromatous,  although  the  advanced  age  of  many 
of  the  patients  makes  it  probable  that  the  elasticity  of  the  vessels  was 
diminished. 

1  Korte  (second  paper)  :  Arcli.  fiir  kliiiisclie  Chinirgic,  vol.  Ixvi. 

2  Hessmanu  :   Minicheiier  incd.  Wocheiiscluirt,  1905,  No.  '[•>. 

3  Possibly  to  these  may  be  addi^d  Volkinaiui's  case  of  wound  oT  tlic  axillary  vein, 
thought  to  have  been  caused  l)y  a  splinter  ol'  bone.  Tlie  wound  was  discuven  il  dining 
an  operation  to  excise  the  head. 


532  DISLOCATIONS. 

In  more  than  half  the  cases  the  dislocation  was  recent — less  than 
three  weeks.  In  not  more  than  one  third  of  them  it  is  reasonably 
certain  that  the  lesion  was  caused  during  reduction  ;  in  three  cases  it 
was  certainly  caused  by  the  dislocation ;  in  the  remainder  the  cause  is 
obscure.  To  these  latter  belong  those  cases  in  which  the  reduction 
was  promptly  effected,  and  without  the  use  of  much  force  or  of  exag- 
gerated positions  of  the  arm.  In  many  of  the  others  the  attempt  to 
make  reduction  was  greatly  prolonged  or  several  times  repeated,  and 
the  force  used  was  very  great  or  improperly  applied. 

In  some  the  injury  was  evidently  caused  by  excessive  traction  ;  in 
others  by  faulty  manoeuvres,  such  as  extreme  abduction  or  elevation  of 
the  arm,  rotation,  and  circumduction  ;  in  others  again  apparently  by 
direct  compression  of  the  vessel  against  the  underlying  bone,  as  by  the 
booted  heel  in  the  axilla,  or  possibly  by  the  thumbs. 

Leaving  aside  the  earlier  cases  in  wiiich  faulty  methods  no  longer  in 
use  were  employed,  and  those  old  dislocations  in  which  the  relations 
and  connections  had  been  permanently  changed  by  fibrous  or  bony 
tissue  of  new  formation,  it  becomes  evident  that  in  dislocation  of  the 
shoulder  the  accident  is  most  to  be  apprehended  when  the  elbow  is 
raised  in  abduction  to  the  height  of  the  shoulder,  or  is  carried,  as  in  Cal- 
lender's  and  Weir's  cases,  across  the  chest  and  face  in  a  wide  movement 
of  circumduction  ;  and  for  this  reason,  that  in  these  movements  the  dis- 
located head  of  the  bone  is  turned  downward  into  the  axilla,  and  the 
vessels  which  lie  upon  its  inner  side  are  pressed  down  before  it  and 
forcibly  put  upon  the  stretch,  while  those  branches  which  run  almost 
directly  outward,  the  subscapular  and  circumflex,  and  are  fixed  to  the 
tissues  amid  which  they  branch,  are  directly  and  forcibly  elongated. 
Although  in  dislocation  inward  the  limb  is  shortened  by  being  ab- 
ducted, yet  the  artery  is  not  thereby  relaxed,  but,  on  the  contrary  is 
still  further  stretched  around  the  head  of  the  bone.  J5ssel,^  in  a  recent 
case  in  which  death  was  caused  by  associated  injuries,  found  the  "  nerves 
of  the  brachial  plexus,  especially  the  circumflex  nerve  and  the  sub- 
scapular artery,  greatly  stretched  by  the  head  of  the  humerus ; "  and, 
according  to  Korte,^  he  found  in  another  case  of  recent  dislocation  the 
subscapular  artery  torn. 

In  some  of  the  cases  in  which  it  is  certain  or  probable  that  the  injury 
to  the  vessels  was  inflicted  at  the  moment  of  dislocation,  it  is  noted  that 
the  latter  was  produced  while  the  arm  was  widely  abducted — that  is, 
under  circumstances  in  which  the  head  of  the  humerus  would  be  driven 
downward  and  inward. 

If  the  dislocation  is  an  old  one,  and  especially  if  there  has  been 
much  inflammatory  reaction,  and  the  vessels  have  become  firmly  adher- 
ent to  the  bone  or  embedded  in  unyielding  cicatricial  tissue,  the  lia- 
bility to  rupture  is  increased,  because  of  the  loss  of  elasticity  occasioned 
by  the  latter  condition,  and  because  of  the  limitation  of  the  strain  to 
a  shorter  segment  of  the  vessel  in  the  former.  If,  in  addition,  the 
distensibility  of  the  vessel  has  been  further  reduced  by  atheroma,  the 
danger  is  still  greater ;  and  this  last  predisposing  cause  may  properly 

1  Jossel :  Deutsche  Zeitschrift,  1880,  vol.  xiii.  p.  177. 
^  Korte  (first  paper) :  Loc.  cit.,  p.  640. 


ACCIDENTS  BY  ATTEMPTS  TO  REDUCE  A   DISLOCATION.     533 

be  deemed  sufficient  to  lead  to  the  rupture,  even  when  the  traction  is 
slight  and  the  manoeuvres  are  confined  within  a  narrow  range. 

The  symptoms  at  the  beginning  present  two  widely  different  forms ; 
in  one,  the  less  common,  a  tumor  presenting  many  of  the  signs  of  an 
encysted  aneurism  appears  in  the  axilla  a  few  days  or  weeks  after 
the  reduction,  and  increases  in  size  rather  rapidly  ;  if  not  successfully 
treated,  it  soon  involves  the  skin  and  ruptures  externally. 

In  the  other  form,  the  more  common,  a  diffused  fluctuating  swelling, 
without  bruit  or  pulsation,  appears  immediately,  or  within  a  few  hours, 
in  the  axilla,  raising  the  pectoral  and  deltoid  muscles,  or  is  perhaps 
most  prominent  posteriorly,  and  in  most  cases  promptly  reaches  a  large 
size,  even  that  of  the  adult  head  (Lister) ;  the  radial  pulse  sometimes 
persists.  The  only  exception  to  rapid  growth  among  the  recorded  fatal 
cases  is  Korte's  third  case,'  in  which  the  extravasated  blood  disap- 
peared slowly,  leaving  a  firm,  non-pulsating  lump,  as  large  as  a  walnut, 
in  the  course  of  the  axillary  artery,  which  a  surgeon  supposed  to  be  a 
Ivmphatic  gland,  and  undertook  to  extirpate  nearly  five  months  after 
tlie  accident.  It  proved  to  be  an  aneurism  containing  much  stratified 
clot;  the  axillary  artery  was  tied  above  and  below,  and  the  patient  died. 

In  several  cases  the  patients  died  promptly  after  the  accident,  some- 
times after  profound  syncope,  sometimes  after  a  short  period  of  appar- 
ent well-being,  with  symptoms  of  shock  or  acute  anaemia.  In  two, 
which  finally  ended  in  recovery,  the  patients  were  at  first  greatly  pros- 
trated, and  death  by  syncope  threatened.  In  another  gangrenous 
emphysema  developed  in  the  arm,  and  the  patient  died  forty  hours 
after  the  reduction.  In  this  case  the  inner  and  middle  coats  of  the 
artery  were  torn  across  "just  beyond  the  point  of  origin  of  the  dorsal 
scapular  branch."  The  radial  pulse  was  at  first  perceptible,  but  had 
ceased  the  next  morning. 

In  most  of  the  others  the  swelling  increased,  and,  in  a  longer  or 
shorter  time,  ruptured  spontaneously,  or  was  threatening  to  rupture 
when  operative  interference  (puncture,  incision,  or  ligature  of  the  sub- 
clavian) was  resorted  to.  The  longest  period  was  in  Bellamy's  case, 
six  months  after  reduction,  and  even  in  this  case  the  first  hemorrhage 
occurred  five  weeks  after  reduction. 

In  eight  cases  that  recovered  without  operation,  the  swelling  subsided, 
and  the  ecchymosis  M'as  slowly  absorbed.  Probably  in  some  of  them 
the  vessel  injured  was  one  of  the  branches  of  the  axillary  artery,  but 
in  at  least  one  (Sands)  the  injury  was  certainly  of  the  artery  itself. 

In  the  three  cases  in  which  rupture  of  the  vein  alone  was  demon- 
strated post  mortem  (Froriep,  Weir,  Price),  the  patients  died  promptly, 
in  an  hour  and  a  half,  five  hours,  and  on  the  following  day  respectively. 

The  histories  show  that,  although  the  diagnosis,  so  far  as  the  general 
nature  of  the  accident,  rupture  of  a  bloodvessel,  is  concerned,  does  not 
long  remain  obscure,  the  identity  of  the  injured  vessel  cannot  always 
be  determined.  If  the  tumor  pulsates,  the  diagnosis  of  rupture  of  an 
artery  may  be  made  ;  and  if,  in  addition,  the  radial  ])ulsc  is  j)resent,  it 
is  extremely  probable  that  the  injured  vessel  is  not  the  main  artery, 
but  that  one  of  its  branches,  proba])ly  the  subscapular  or  circumflex, 

'  KiJrte  (first  paper) :  Loc.  cit.,  p.  ().3(). 


534  DISLOCATIONS. 

has  been  ruptured  or  torn  off  at  its  origin.  Beyond  this  it  does  not 
seem  at  present  possible  to  go  with  much  certainty,  although  the  great 
preponderance  of  arterial  lesions  in  the  known  cases — 26  out  of  29 — 
makes  it  liighly  probable  in  any  given  case  that  an  artery  and  not  the 
axillary  vein  has  been  torn. 

The  terminations  were  as  follows  :  22  recoveries,  33  deaths,  and  in  1 
(Green's)  the  result  is  unknown  ;  21  received  no  operative  treatment ; 
of  these  6  recovered  and  15  died.^  In  19  the  subclavian  was  tied, 
with  8  recoveries  and  1  after  disarticulation,  8  deaths,  and  2  unknown 
result.  In  1  a  cure  was  effected  by  digital  pressure  on  the  subclavian, 
and  in  1  by  stuflfing  the  cavity  with  gauze  (ant.  circumflex).  In  6  an 
incision  was  made  in  the  axilla,  and  the  artery  tied  above  and  below 
the  point  of  rupture  ;  all  died.  In  one  (Korte's  second)  the  small 
opening  in  the  artery  was  sutured,  and  after  a  hemorrhage  on  the 
twenty-second  day  the  artery  was  tied  above  and  below.  The  patient 
recovered  with  a  useless  limb  after  prolonged  gangrene  and  suppura- 
tion. In  one  (Raw)  the  torn  subscapular  artery  and  axillary  vein  were 
tied,  the  patient  recovering.  In  4  the  limb  was  disarticulated ;  1 
recovery,  3  deaths.  The  treatment  in  the  cases  that  recovered  without 
operation  was  simply  compression  of  the  swelling  and  immobilization 
of  the  arm,  with  the  application  of  ice  in  Malgaigne's,  and  compression 
of  the  subclavian  artery  in  Agnew's. 

In  drawing  inferences  from  these  results,  it  must  be  borne  in  mind 
that  in  many  of  the  cases  in  which  operations  were  undertaken  non- 
operative  treatment  had  previouly  been  employed,  and  had  resulted 
in  a  condition  that  made  an  operation  necessarv.  Including  such,  the 
results  of  non-operative  treatment  may  be  tabulated  as  follows  :  Of 
38  patients,  6  recovered,  15  died,  and  17  (with  10  deaths)  subse- 
quently underwent  operation,  either  because  death  by  hemorrhage 
threatened  or  because  of  the  existence  of  a  growing  aneurism.^  A 
fair  inference  from  the  reported  cases  is  that  conservative  treatment 
may  properly  be  tried  at  first,  but  should  not  be  prolonged  if  the 
symptoms  do  not  promptly  yield ;  and,  secondly,  that,  in  case  of 
resort  to  operation,  ligature  of  the  subclavian  artery  or  disarticulation 
at  the  shoulder  is  to  be  preferred  to  incision  of  the  sac  and  double 
ligature  of  the  artery.  It  is  not  easy  to  understand  why  ligature  of 
the  artery  above  and  below  has  been  so  uniformly  fatal,  and  notwith- 
standing the  record  I  should  prefer  it  to  disarticulation,  and  perhaps 
even  to  ligature  of  the  subclavian. 

Experience  with  arteries  wounded  under  other  conditions  has  shown 
that  they  will  sometimes  quite  readily  heal,  or  the  opening  made  into 
them  will  close,  under  pressure  accurately  made  at  the  point  of  injury, 
and  it  would,  therefore,  be  proper  to  attempt  to  treat  this  injury  by 
direct,  limited  pressure.  Whether  or  not  it  would  be  possible  to 
recognize  the  wounded  point  and  make  efficient  pressure  directly  upon 
it  cannot  be  said,  since  the  attempt  does  not  appear  to  have  been 

1  Possibly  Korte's  second  case  should  be  inclucled  among  the  recoveries. 

2  Korte's  second  case  is  an  exception  ;  an  error  in  diagnosis  led  to  an  operation  after 
the  aneurism  had  apparently  undergone  spontaneous  cure.  In  Caldwell's  the  swelling 
was  thought  to  be  au  abscess. 


ACCIDENTS  BY  ATTEMPTS   TO   REDUCE  A   DISLOCATION.    535 

made.  In  default  of  such  limited  pressure,  general  compression  of 
the  swelling  in  the  axilla  seems  to  be  the  only  resource  short  of  opera- 
tion. The  common  treatment  of  ruptured  artery,  incision  and  double 
ligature  of  the  vessel,  was  immediately  resorted  to  in  only  two  of  these 
cases ;  both  were  promptly  fatal.  Korte's  result  after  lateral  ligature 
of  a  small  opening  in  the  artery  is  not  encouraging,  although  a  number 
of  successes  after  incised  wounds  have  been  reported. 

In  the  reduction  of  recent  dislocations,  these  accidents  show  that 
abduction  of  the  arm  especially  should  be  avoided,  as  also  circumduc- 
tion, violent  traction,  and  rough  pressure  in  the  axilla.  Kocher's 
method  by  manipulation  and  mine  by  the  unsupported  weight  of  the 
dependent  limb  appear  well  adapted  to  avoid  the  danger.  It  is  also  to 
be  remembered  that  the  injury  to  the  vessel  may  be  caused  by  the 
dislocation  itself,  and  its  symptoms  may  be  masked  by  the  swelling 
commonly  present  during  the  hrst  few  days. 

In  old  dislocations  the  probability  of  the  occurrence  of  the  accident 
is  increased  by  the  more  forcible  measures  usually  necessary  to  break 
up  the  adhesions  that  bind  the  bones  in  their  new  relations;  and, 
wiiile  it  may  be  proper  in  many  cases  to  make  the  attempt  to  restore 
the  limb  to  usefulness,  the  possibility  creates  another  reason  for 
abstention  when  the  patient  is  old,  the  duration  of  the  dislocation  long, 
and  the  adhesions  firm.  Even  a  dislocated  arm  may  be  very  useful, 
and  the  fatality  of  this  accident,  more  than  70  per  cent,  of  deaths, 
may  well  cause  the  surgeon  to  hesitate  to  incur  the  risk  merely  for  the 
sake  of  ameliorating  a  condition  which  does  not  endanger  life  and  is 
quite  compatible  with  activity  and  usefulness. 

Injuries  to  Nerves.  These  also  have  been  far  more  frequently 
observed  at  the  shoulder  than  elsewhere,  and  there  is  the  same  diffi- 
culty in  many  of  the  recorded  cases  in  determining  whether  the  injury 
was  caused  by  the  dislocation  or  by  the  manoeuvres  employed  to 
eifect  a  reduction. 

The  injury  may  consist  in  direct  compression  of  the  nerve  against 
the  bone,  as  in  attempted  reduction  by  the  method  of  the  door  or 
ladder  or  by  the  heel  in  the  axilla,  or  in  forcible  elongation  or  com- 
plete rupture  of  the  nerve  by  traction  upon  the  limb,  or  such  change 
in  its  position  that  the  nerve  is  stretched  around  the  head  of  the  bone, 
or  in  avulsion  of  the  nerve  from  the  spinal  cord.  As  the  auto]isies 
are  few  in  number  our  knowledge  of  the  lesions  is  mainly  clinical. 
In  a  case  quoted  in  the  preceding  section,  one  of  rupture  of  the  brachial 
artery  near  the  elbow,  the  median  nerve  was  also  ruptured  ;  and  this 
double  injury  has  been  several  times  encountered  in  compound  dislo- 
cation of  the  elbow. 

In  a  case  reported  by  Flaubert,'  and  mentioned  above  in  the  section 
on  Emphysema,  a  dislocation  of  tiie  left  shoulder  five  weeks  old  in  a 
very  stout  M'oman  aged  seventy  years,  reduction  was  accomplislied 
with  difficulty  after  prolonged  traction  upon  the  arm  by  eight  assist- 
ants.    Beside  the  emphysema  extending  over  the  neck  and  back,  there 

1  Marchand  :  Loc.  cit.,  pp.  25,  U7. 


536  DiSLOCA  Tioys. 

were  syncope  lasting  an  hour,  cloudiness  of  vision,  paralysis  of  the 
right  arm,  and  left  hemij^legia  with  loss  of  sensibility  in  the  left  arm 
but  with  pain  referred  to  it.  Thirty-six  hours  later  there  was  sharp 
pain  in  the  back  of  the  head  and  neck  and  in  thf;  ears ;  pain  also  in 
the  left  thigh,  in  which  sensation  was  better  than  m  the  right ;  the 
left  arm  was  insensitive,  without  pain,  and  motionless  ;  the  right  arm 
numb  and  somewhat  weakened ;  pulse  rapid,  skin  warm.  The  next 
day  the  pupils  were  dilated  and  did  not  respond  to  light.  On  the  sev- 
enteenth day  the  respiration  was  embarrassed,  the  skin  hot,  pulse 
rapid,  prostration  great ;  and  on  the  nineteenth  day  death.  Tlie 
autopsy  showed  the  lower  four  pairs  of  the  brachial  plexus  on  the  left 
side  to  have  been  torn  away  from  the  spinal  cord ;  the  torn  ends 
plainly  showed  the  delicate  filaments  by  which  they  took  their  origin, 
and  the  ganglions  on  the  posterior  roots  could  be  distinguished.  The 
first  pair  had  suffered  no  injury.  The  spinal  dura  mater  was  of  a  dark 
brown-red  color,  and  the  cord,  at  the  point  where  the  nerves  had  been 
torn  away,  was  changed  into  a  reddish-brown  pulp  in  which  the  gray 
and  white  substances  seemed  mingled. 

The  two  following  cases  recorded  by  Flatibert  ^  bear  a  close  resem- 
blance clinically  to  this  one. 

In  a  man,  fifty  years  old,  with  a  dislocation  of  the  shoulder  dating 
from  a  fortnight  before,  traction  by  three  assistants  caused  numbness 
and  pain  in  the  hand  and  wrist ;  a  second  attempt,  with  six  assistants, 
instantly  caused  numbness  in  the  corresponding  leg,  and  the  reduction 
was  abandoned.  The  following  night  there  was  sharp  pain  in  tlie 
lower  cervical  vertebrae,  subsequently  extending  to  the  dorsal  region. 
The  arm  remained  almost  completely  paralyzed. 

A  dislocation  of  the  shoulder  seven  weeks  old  in  a  woman  sixty-four 
years  of  age  was  reduced  by  traction  made  by  five  assistants.  At  the 
moment  of  reduction  the  patient  felt  a  sort  of  rupture  at  the  wrist, 
followed  by  a  quivering  that  extended  to  the  L^wer  third  of  the  arm 
and  by  complete  hemiplegia  and  great  diminution  of  sensation  on  the 
same  side,  especially  in  the  arm.  The  lower  limb  regained  its  power, 
but  the  arm  remained  paralyzed  and  atrophied. 

In  other  cases  the  effects,  as  indicated  by  the  symptoms,  have  been 
limited  to  the  limb,  arm  or  leg,  or  to  portions  of  it, 

Erichsen  -  quotes  from  Billroth  a  case  of  dislocation  of  the  shoulder 
of  nine  months'  standing  which  had  been  accompanied  by  partial 
paralysis  of  the  arm  and  some  atrophy.  The  reduction  was  followed 
by  total  paralysis.  Le  Bret'^  reported  one  which  occupies  a  position 
intermediate  between  this  class  and  the  preceding  :  a  soldier  dislocated 
his  right  shoulder  ;  reduction  was  immediately  made  by  traction,  and 
was  followed  by  paralysis  of  motion  in  the  entire  arm,  loss  of  sensa- 
tion below  the  elbow  and  on  the  right  side  of  the  neck,  and  by  ptosis 
and  dimness  of  vision  on  the  same  side.  In  most  of  the  more  recent 
recorded  cases  the  history  leaves  it  in  doubt  whether  the  paralysis  was 

^  Quoted  Ijy  Malgaigue  :  Loc.  cit..  pp.  158.  159. 

'  Erichsen  :  Surgerv,  Am.ed.,  vol.  i.  p.  415. 

3  Le  Bret :  Soc.  de  Biologie,  1854,  p.  119.     Quoted  bx  Weir  Mitchell. 


ACCIDENTS  BY  ATTEMPTS  TO  REDUCE  A  DISLOCATION.   537 

caused  bv  the  dislocation  or  by  the  reduction.  In  the  older  cases, 
in  which  the  rough  method  of  the  door,  ladder,  or  ambi  was  employed 
for  reduction,  there  can  be  but  little  doubt  that  the  jjaralysis  was  com- 
monly caused  by  the  reduction.  At  the  shoulder  the  nerve  most 
frequently  aifected  is  the  circumflex  ;  ^larchand  tliinks  this  nerve  is 
commonly  injured  by  the  dislocation;  the  others  by  the  reduction. 
Instances  of  injury  in  other  dislocations  than  those  of  the  shoulder  are 
rare.  Hutchinson  ^  describes  a  case  of  ischiatic  dislocation  of  the 
femur  reduced  by  manipulation  under  ether,  followed  by  com])lete 
anaesthesia  of  the  limb  below  tlie  knee  except  on  the  inner  side  of  it 
and  of  the  foot. 

Maclise"  gives  a  plate  of  dislocation  of  the  femur  backward  in  which 
the  sciatic  nerve  is  stretched  over  the  neck  of  the  bone ;  and  he  says  : 
"  In  general  (in  dislocations  into  the  sciatic  notch)  the  great  sciatic 
nerve  is  bent  over  the  femur  and  put  on  the  stretch."  .  .  .  "I 
have  seen  it  so  situated  in  regard  to  the  head  of  the  femur  that  the 
reduction  could  not  possibly  have  been  effected  with  safety  to  that 
nerve."  The  plate  apparently  represents  a  dislocation  produced  upon 
the  cadaver,  and  it  seems  probable  that  the  text  refers  to  dislocations 
similarly  produced.  I  have  known  of  only  one  clinical  case  in  which 
such  relations  of  the  parts  have  been  observed  (Quaiu's). 

Fracture.  Fracture  of  the  dislocated  l)one  during  reduction  has 
occurred  in  dislocations  of  the  shoulder,  elbow,  and  hip,  and  not  only 
Avhen  great  force  has  been  employed,  but  also  during  comparatively 
gentle  manipulations  to  flex,  abduct,  or  rotate  the  limb. 

At  the  shoulder  the  recorded  cases  appear  all  to  have  been  disloca- 
tions of  long  standing  in  elderly  people,  and  in  most  the  accident  was 
caused  by  forcible  rotation  during  traction.  Of  late  years  I  have 
heard  of  several  cases  of  fracture  in  comparatively  recent  dislocations 
caused  by  attempts  to  reduce  by  Koclier's  method.  The  fracture  is 
usually  at  or  just  below  the  surgical  neck. 

Several  authors  assert  that  the  ribs  have  been  broken  during  reduc- 
tion by  the  pressure  of  a  firm  axillary  pad  used  as  a  fulcrum,  and  also 
say  that  the  lip  of  the  glenoid  cavity  maybe  bi-oken  during  reduction. 
In  Weir's  case,  quoted  on  page  512,  the  third,  fourth,  and  fifth  ribs 
were  broken  in  the  axillary  line,  apparently  by  pressure  of  the  heel. 

At  the  elbow  fracture  of  the  olecranon  has  been  frequently  caused, 
either  intentionally  or  by  accident,  in  the  reduction  of  old  dislocations. 
There  is  but  one  recorded  case  of  its  fracture  in  a  recent  dislocation, 
and  even  in  this  there  is  some  doubt  whether  the  fracture  liad  not  taken 
place  before  the  reduction  was  attempted.-^ 

Markoe*  mentions  a  case,  ajjparently  unique,  of  fracture  of  the 
humerus  in  an  attempt  to  reduce  an  old  dislocation  of  the  elbow. 
"While  making  extension,  and  at  the  same  time  trying  to  flex  tlie 
forearm   on  the  arm,   the  humerus  gave  way,  and  a  very  ol)lique  frac- 

1  Hutchinson:  Medical  Times  and  Gazette,  1866,  i.  p.  194. 
-  Maclise:  Dislocations  and  Fractures,  Plate  xxv.  Fig.  2. 
^  Daugier.  in  Malgaigne :  Loc.  cit.,  p.  146. 
*  Markoe :  Diseases  of  the  Bones,  p.  18, 
38 


538  DISLOCATIONS. 

ture  was  found  to  have  occurred  about  a  hand's  breath  above  the 
joint." 

I  have  seen  one  case  of  backward  dislocation  at  the  elbow  in  which 
a  forcible  change  of  the  position  from  full  extension  to  flexion  at  a 
right  angle  had  broken  off  the  trochlear  portion  of  the  humerus  and 
displaced  it  forward  and  upward. 

In  dislocations  of  the  hip  the  femur  has  been  broken,  usually  at  the 
neck,  but  once  at  least  at  the  lower  end  of  the  shaft ;  and  it  is  asserted 
by  some  that  the  rim  of  the  acetabulum  also  has  been  broken.  The 
accident  appears  to  have  been  due  not  to  traction,  but  to  efforts  made 
by  the  hands  of  the  surgeon  to  change  the  position  of  the  limb,  rota- 
tion or  abduction.  Although  the  force  thus  applied  is  slight  compared 
with  that  developed  by  the  use  of  pulleys,  it  must  be  remembered  that 
its  effect  is  greatly  increased  by  the  leverage  of  the  limb. 

Inflammation,  Suppuration,  Gangrene.  The  inflammatory  reaction 
induced  by  a  dislocation  is  usually  moderate,  and  rarely  terminates  in 
suppuration  ;  and  when  excessive  reaction  does  follow  the  reduction  of 
a  recent  dislocation,  it  is  not  always  possible  to  determine  whether  the 
original  traumatism  or  the  reduction  is  responsible  for  it.  In  disloca- 
tions of  long  standing  this  difliculty  does  not  exist,  for  the  primary 
reaction  has  completely  subsided,  or,  if  persistent,  has  become  moderate 
and  chronic  before  the  reduction  is  attempted,  and  its  renewal  or  exacer- 
bation is  plainly  due  to  the  interference. 

The  inflammation  may  be  due  to  the  direct  pressure  of  the  apparatus 
used  for  making  traction,  or  to  laceration  of  the  parts  about  the  affected 
joint;  the  latter  is  the  more  dangerous  because  of  the  probability  that 
the  inflammation  and  suppuration  may  extend  to  the  cavity  of  the 
joint,  but  the  former  also  has  proved  fatal. 

Of  laceration  of  the  parts  about  the  aflected  joint  the  following  case 
is  an  example.  It  was  under  the  care  of  Malgaigne,  is  briefly  referred 
to  by  him,^  and  is  reported  in  full  by  Parmentier  :^  A  man,  thirty-four 
years  old,  with  an  intracoracoid  dislocation  of  six  months'  standing. 
Three  attempts  to  reduce  were  made,  the  traction  in  the  last  amounting 
to  more  than  four  hundred  pounds,  and  the  head  of  the  bone  being 
brought  almost  back  to  its  place,  but  an  attempt  to  force  it  into  place 
by  lateral  traction  with  a  bandage  failed  and  even  lacerated  the  skin 
on  the  posterior  margin  of  the  axilla.  On  the  fifth  day  after  the  last 
attempt  the  patient  complained  of  pain  in  the  axilla,  and  the  following 
day  became  delirious,  and  a  large  quantity  of  pus  escaped  through  the 
laceration  of  the  skin  ;  trismus  and  tetanus  followed,  and  death  two 
days  later. 

The  autopsy  showed  abscesses  under  and  behind  both  pectoral  mus- 
cles, in  the  substance  of  the  coraco-brachialis  and  along  its  under  sur- 
face, and  communicating  with  the  new  articular  cavity  through  a  rent 
in  its  capsule. 

The  following  case,  reported  by  Mr.  Jonathan  Hutchinson,''  is  even 
more  striking.     An  elderly  woman,  drunk,  was  admitted  with  a  dislo- 

1  Malgaigne  :  Loc.  cit.,  p.  168.    ^  Parmentier  :  Bull,  de  la  Soc.  Anatomique,  1852,  p.  302. 
3  Hutchinson  :  Medical  Times  and  Gazette,  1866,  vol.  i.  p.  304. 


ACCIDENTS  BY  ATTEMPTS   TO   REDUCE  A   DISLOCATION.     539 

cation  into  the  axilla ;  an  attempt  to  rednce  failed.  The  next  dav  she 
said  the  shoulder  had  been  dislocated  for  several  years,  but  she  was  not 
believed,  and  reduction  was  again  attempted  with  the  aid  of  chloro- 
form by  moderate  manual  traction  directly  outward  and  the  knee  in 
the  axilla  as  a  fulcrum  ;  the  attempt  was  continued  for  ten  minutes. 
Great  inflammation  followed,  the  joint  suppurated,  and  the  patient 
died.  The  autopsy  showed  a  new  articular  cavity  formed  below  and 
in  front  of  the  glenoid  cavity.  The  soft  tissues  of  the  joint  were 
wholly  destroyed  by  suppuration,  and  every  trace  of  cartilage  removed. 

An  experience  of  Broca's  shows  that  an  unfortunate,  even  fatal, 
result  may  follow  an  apparently  judicious  and  moderate  attempt  at 
reduction. 

The  patient,^  a  coachman,  thirty-nine  years  old,  entered  the  hospital 
for  treatment  six  months  after  he  had  dislocated  his  left  hip.  Trac- 
tion to  the  amount  of  more  than  five  hundred  pounds  was  made  wdth 
Mathieu's  apparatus  without  success,  and  the  attempt  was  not  repeated. 
No  ill  result  appearing,  the  patient  was  discharged  at  the  end  of  a  week. 
A  fortnight  later  he  was  admitted  to  another  hospital  with  considerable 
swelling  of  the  hip  and  peritonitis,  and  died  on  the  following  day. 
The  autopsy  showed  a  collection  of  pus  occupying  the  old  and  new 
articular  cavities,  filling  the  external  iliac  fossa,  infiltrating  the  gluteus 
medius,  and  in  contact  with  the  entire  surface  of  the  internal  and  exter- 
nal obturators  and  with  the  obturator  foramen  ;  also  a  generalized  peri- 
tonitis, much  more  marked  in  the  true  pelvis  than  elsewhere.  The 
course  of  the  lesion  Avas  thought  to  have  been  :  inflammation  of  the 
new  joint,  extension  to  the  old  one,  then  to  the  obturator  internus,  and 
finally  to  the  peritoneum.  It  was  thought  probable  that  the  patient 
had  resumed  work  immediately  after  leaving  the  hospital,  and  that  this 
untimely  use  of  the  limb  had  provoked  the  suppuration. 

In  a  few  recorded  cases  the  inflammatory  reaction  was  so  severe  that 
the  limb,  or  the  afl'ected  segment  thereof,  became  gangrenous.  Dupuy- 
tren  ^  reported  a  case  in  which,  after  reduction  of  a  dislocation  of  the 
thumb  by  long  and  violent  efforts,  the  thumb  became  gangrenous  and 
separated  at  the  metacarpo-phalangeal  joint. 

These  cases  are  to  be  distinguished  from  those  in  which  gangrene 
has  been  caused  by  injury  to  the  vessels  or  nerves,  as  in  La  Motte's 
case,^  Weir's  first  case  quoted  in  Chapter  XXXIII.,  page  524,  and 
probably  in  Delagarde's/  in  which,  after  reduction  of  an  old  dislocation 
of  the  shoulder,  abscesses  and  points  of  gangrene  formed  in  the  limb 
and  rendered  amputation  at  the  shoulder  necessary. 

Persistent  oedema  of  the  limb,  a  condition  resembling  elephantiasis, 
has  been  observed  in  a  few  cases  in  which  unsuccessful  attempts  had 
been  made  to  reduce  old  dislocations,  apparently  the  result  of  inter- 
ference with  the  venous  flow.  In  a  case  of  Malgaigne's,  quoted  by 
Velpeau,'' the  fpdema  of  the  arm  disappeared  simultaneously  with  the 
development  of  numerous  varicose  veins  in  the  arm  and  shoulder. 

1  Eeported  by  Tillaux  in  Bull,  de  la  Soc.  de  Chir.,  1868,  vol.  ix.  p.  266. 

2  Dupuytren  :  Quoted  by  Marchand,  loc.  cit.,  p.  129. 
^  I^a  Motte  :  Traite  de  Chirurgio,  vol.  Iv.  p.  343. 

*  Dclagarde  :  St.  Bartholomew's  Hospital  Reports,  vol.  iv.  p.  89. 

*  Marchand:  Loc.  cit.,  p.  131. 


540  DISLOCATIONS. 

Syncope  and  Sudden  or  Early  Death ;  Fat  Embolism.  Beside 
the  numerous  cases  already  quoted,  in  this  chapter  which  show  the 
dangers  to  the  life  of  the  patient  that  may  arise  in  the  course  of  an 
attempt  to  reduce  a  recent  or  an  old  dislocation,  there  are  still  others 
which  indicate  that  life  may  be  seriously  threatened,  or  even  destroyed, 
by  other  accidents  or  complications  than  the  rupture  of  important 
vessels  or  nerves  or  excessive  reaction  and  suppuration.  In  some  of 
the  fatal  cases  the  failure  to  make  an  autopsy  leaves  the  cause  of  death 
obscure,  but  the  symptoms  point  to  rupture  of  a  vessel  as  a  possible 
cause. 

E.  Boeckel  ^  has  reported  a  case  the  autopsy  of  which  suggests  another 
explanation,  not  only  of  some  of  the  deaths  by  syncope,  but  also  of 
some  attributed  to  the  ansesthetic. 

The  patient  was  a  man  fifty  years  of  age,  with  a  recent  ilio-pubic 
dislocation,  who  was  brought  to  the  hospital  after  an  unsuccessful 
attempt  to  reduce.  Chloroform  was  given  and  reduction  made  in  seven 
minutes  ;  the  patient  grew  pale,  his  respiration  weakened  and  promptly 
stopped.  The  autopsy  showed  the  heart  to  be  atrophied,  both  pulmon- 
ary arteries  plugged  by  non-adherent  clots,  rounded  like  emboli,  in  the 
medium-sized  branches  and  those  of  the  third  and  fourth  order,  and 
also  fat  embolism  of  the  lungs  very  widespread  and  intense.  The  iliac 
and  femoral  veins  were  free,  but  there  was  a  thrombus  in  the  popliteal 
vein  from  which  it  was  thought  those  in  the  pulmonary  arteries  had 
been  broken  off. 

Before  the  use  of  anaesthetics,  in  the  times  when  muscular  resolution 
was  sought  to  be  obtained  by  measures  which  depressed  and  weakened 
the  patient,  and  when  the  efforts  to  reduce  were  made  with  great  vio- 
lence and  sometimes  prolonged  for  hours,  exhaustion  of  the  patient 
habitually  followed,  and  death  was  sometimes  the  consequence. 

Death  by  the  action  of  an  ancesthetic,  especially  chloroform,  is 
thought  to  occur  in  a  larger  proportion  of  cases  of  reduction  of  dislo- 
cation than  of  other  operations,  but  no  satisfactory  explanation  of  the 
greater  risk,  if  it  actually  exists,  has  been  given.  Of  134  cases  of 
death  by  an  ansesthetic  collected  by  Marchand,  in  17  the  operation  was 
the  reduction  of  a  dislocation ;  of  these  11  were  of  the  shoulder,  3  of 
the  hip,  and  1  each  of  the  knee,  elbow,  and  thumb. 

'  E.  BcEckel :  Mort  subite  par  embolies  pulraonaires,  simulant  la  mortpar  le  chloroform 
apres  reduction  d'une  luxatiou  de  la  cuisse.  Kev.  des  Sciences  Med.,  Oct.  15,  1881,  p.  637. 


CHAPTER    XXXV. 

CONGENITAL  DISLOCATIONS. 

The  term  "congenital"  has  been  rather  loosely  used  to  include 
almost  all  dislocation?  noted  at  or  shortly  after  birth,  with  or  without 
an  actual  determination  of  the  time  of  occurrence.  Later  observation 
has  shown  not  only  notable  differences  among  them  in  etiology  and 
pathology  but  also  that  some  are  traumatic,  occurring  as  the  result  of 
violence  either  before  or  during  birth,  and  others  are  gradually  pro- 
duced in  the  first  few  days  after  birth  as  the  result  of  paralysis  of  a 
few  muscles,  itself  occasioned  during  delivery.  This  last  form  occurs 
with  great  relative  frequency  at  the  shoulder  and  will  be  considered 
in  detail  in  Chapter  XLIV. 

In  this  chapter  dislocations  at  the  hip  will  be  almost  exclusively 
considered.  Their  existence  in  the  new-born  child,  and  their  non- 
traumatic character,  have  been  recognized  since  the  earliest  times, 
but  the  accurate  study  of  the  subject  may  be  said  to  have  begun  in 
1818,  with  Schreger,  who  examined  postmortem  two  specimens  in  a 
girl  two  and  a  half  years  old  and  a  woman  of  forty-eight.  A  few  years 
later,  1826,  Dupuytren  brought  the  subject  before  the  Academic  des 
Sciences,  and  called  attention  expecially  to  the  facts  that  the  affection 
was  often  inherited,  and  often  bilateral.  Since  then  the  subject  of 
congenital  dislocation  of  the  hip  has  been  actively  studied  by  many, 
and  the  similar  but  much  rarer  affections  of  other  joints  have  received 
due  attention. 

Statistics.  Dislocations  have  been  observed  at  birth  in  many  joints, 
but  not  only  do  those  of  the  hip  far  exceed  all  others  in  number,  but 
the  latter  are  actually,  as  well  as  relatively,  so  rare  that  their  statistics 
have  not  much  value.  Kronlein  says  that  the  records  of  Von  Langen- 
beck's  Polyclinic  show  90  congenital  dislocations  of  the  hip,  5  of  the 
shoulder,^  2  of  the  head  of  the  radius,  and  1  of  the  knee.  It  is  not 
exceptional  to  find  several  dislocations  present  in  an  individual,  or 
one  or  more  dislocations  associated  with  such  congenital  defects  as 
spina  bifida,  club-foot,  ventral  hernia,  encephalocele,  and  exstrophy 
of  the  bladder. 

As  will  appear  in  studying  the  etiology  of  this  affection,  the  statistics 
of  congenital  dislocation  of  the  hip  includes  cases  widely  (Hfferent  in 
their  origin,  and  even  some  which  are  acquired  and  not  congenital, 
that  is,  some  which  have  been  produced  during  the  first  few  months  of 
life,  perhaps  before  the  patient  began  to  walk,  by  the  imojiposed  action 
of  certain  groups  of  muscles  after  jiaralysis  of  otiiers.     It  seems  prob- 

'  Probably  all  of  these  were  the  result  of  Ijirth  palsy. 

(  541  ) 


542 


DISLOCATIONS. 


able,  however,  that  the  error  thus  arising  is  not  a  large  one,  but  still, 
for  this  and  for  other  reasons,  I  shall  here  quote  only  the  more  recent 
statistics,  believing  them  to  be  the  most  nearly  correct.  These  are 
Drachmann's,!  Pravaz's  (quoted  by  Kronlein),  and  Kronlein's.^ 


Congenital  Dislocations  of 

Hip. 

Period. 

Cases. 

Male. 

Female. 

Single. 

? 

Left. 

Right. 

Drachmann    . 
Pravaz     .... 
Kronlein 

1865-1880 
1863-1878 
1875-1880 

77 

107 

90 

10 
11 
14 

67 
96 
76 

24, 
27 
32 

24 
29 
22 

5 

29 
51 
31 

Total 

274 

35 

239 

83 

75 

5 

111 

Prahl's^  are  not  given  in  sufficient  detail  to  be  included  in  the  table  ; 
they  comprise  18  cases;  3  were  males,  15  females,  making  with  those 
in  the  table  a  total  of  292,  of  which  38  were  males,  13  per  cent.,  and 
254  females,  87  per  cent.  Angot*  says  that  of  about  20  cases  observed 
by  him  at  the  Hopital  des  Enfants  malades  in  1882,  all  were  girls. 
Of  11  cases  of  congenital  dislocation  of  the  knee  collected  by  Hibon,'^ 
7  were  girls,  3  boys,  and  in  1  the  sex  was  not  recorded ;  of  these,  3, 
1  girl  and  2  boys,  were  stillborn,  and  presented  other  very  marked 
deformities. 

Etiology. 

The  discussion  of  this  branch  of  the  subject,  which  was  taken  up 
with  much  interest  after  the  publication  of  Dupuytren's  memoir,  was 
not  fruitful  of  positive  results  because  of  the  lack  of  anatomical  mate- 
rial and  minute  examination,  and  of  failure  distinctly  to  discriminate 
between  different  forms  and  between  the  original  bony  defects  and  the 
changes  produced  by  the  long  use  of  the  deformed  limb.  Since  the 
affection  is  one  which  often  escapes  recognition  until  the  child  begins  to 
walk,  it  was  sometimes  confounded  with  dislocations  resulting  from 
infantile  paralysis,  and  as  it  is  one  which  does  not  destroy  life  the  op- 
portunities for  direct  anatomical  investigation  were  almost  entirely  re- 
stricted to  two  classes  of  cases,  the  stillborn  and  those  that  died  shortly 
after  birth  in  consequence  of  other  important  congenital  defects,  and 
those  in  which  the  original  changes  had  been  masked  or  supplemented 
by  subsequent  ones  produced  by  the  further  displacement  of  the  head 
of  the  femur  and  its  iibnormal  relations  to  the  adjoining  parts.  In  the 
former,  incorrect  inferences  were  drawn  from  the  associated  defects, 
as  when  the  irritation  of  an  over-full  urinary  bladder  or  the  separa- 
tion  of   the   symphysis  ])ubis   was  deemed   the  immediate   cause   of 

1  Drachmann  :  Schmidt's  Jahrbiich.,  1881,  voL  clxi.  p.  170. 

^  Kronlein  :  Deutsche  Chirurgie,  Lief.  26,  p.  82. 

3  Prahl :  Inaug.  Dis.  Breslau,  1880.     Abst.  in  Centralblatt  fiir  Chir.,  1881,  p.  57. 

*  Angot :  Luxations  congenitales  de  la  hanche.     These  de  Paris,  1883,  p.  11. 

5  Hibon  :  Luxations  congenitales  du  tibia  en  avant.     These  de  Paris,  1881,  p.  7. 


CONGENITAL  DISLOCATIONS.  543 

the  arrest  of  development  of  the  acetahukini ;  and  in  the  latter  the 
attention  was  led  far  astray  by  prominent  changes  in  the  bones.  The 
history  of  the  theories  advanced  has  not  only  an  historical  value,  but  it 
serves  also  to  indicate  certain  varieties  and  prominent  features  of  the 
atfection,  and  therefore  I  append  the  following  resume  made  by  Kron- 
lein.  It  must  be  remembered  that  most  of  the  theories  deal  exclus- 
ively with  dislocations  of  the  hip, 

1.  The  so-called  congenital  dislocation  is  traumatic,  and  arises  : 

a,  through  external  violence  acting  upon  the  foetus  in  utero,  or  through 
the  action  of  the  muscles  of  the  foetus  itself,  Hippocrates  and 
the  early  writers  held  that  mechanical  injuries  of  the  belly  of 
the  mother  could  produce  dislocation  in  the  foetus.  Cruveilhier 
did  not  entirely  reject  this  theory  in  some  cases.  Chatelain, 
Kleeberg,  Zielewicz,  even  specify  in  their  three  cases  the  injury, 
a  fall  in  the  seventh  month,  which,  in  their  opinion,  had  caused 
the  dislocation.-  Chaussier  claims  even  that  a  dislocation  can 
be  caused  by  the  contraction  of  the  muscles  of  the  foetus,  and 
narrates  in  support  the  case  of  a  young  woman  who,  during  the 
ninth  month  of  pregnancy,  felt  on  three  occasions  such  violent 
movements  of  the  child  that  she  almost  became  unconscious. 
When  delivery  took  place  at  term^  the  child  had  a  complete 
dislocation  of  the  left  forearm. 

h,  during  delivery. 

Capuron  (1834)  held  that  some  congenital  dislocations  of  the 
hip  had  been  produced  during  delivery,  by  traction  with  the 
finger  on  the  groin  in  breech-presentations. 

2.  Congenital  dislocation  {of  the  hip)  is  a  spontaneous  dislocation,  and 
is  occasioned : 

a,  by  softening  and  laxity  of  the  ligamentous  portion  of  the  joint  (Sedil- 

lot,  1836),     This  opinion  was  held  in  part  by  Stromeyer  (1840). 

b,  by  foetal  hydrarthrosis  (Parise,  1842)  or  other  joint  affections,  such 

as  fungous  synovitis  with  effusion  (Verneuil  and  Broca),  or 
caries  and  destruction  of  the  capsule  (Morel  Lavallee,  Albers, 
Von  Ammon). 

3.  Congenital  dislocation  (of  the  hip)  is  due  to  the  peculiar  position  of 
the  lower  limbs  of  the  foetus  in  utero. 

a,  it  is  possible  that  in  the  strongly  flexed  position  of  the  hip  the  press- 

ure of  the  head  of  the  femur  upon  the  posterior  or  lower  j)or- 
tions  of  the  capsule  may,  irhen  tJie  latter  is  abnormally  weak 
cause  dislocation  (Dupuytren,  1826), 

b,  congenital  dislocation  of  the  hip  is  due  to  abnormal  adduction  of 

the  thigh  in.  utero,  to  a  compressed  ]:>osition  of  the  foetus  due  to 
deficiency  in  the  amount  of  the  amniotic  liquid  (Roser,  1864). 

4.  Congenital  dislocation  of  the  hip,  like  most  congenital  deformities 
of  the  joints,  such  as  club-foot,  wry  neck,  and  spinal  curvature,  is  the 
result  of  primary  muscular  contraction,  which  is  itself  to  be  regarded  as 
the  result  of  an  affection  of  the  central  nervous  system  (J,  Giu'rin, 
1840,  and,  following  him,  Chaussier,  Melicher,  Mercer-Adam,  C'arno- 
chan,  Erichsen,  and  others), 

5.  Congenital  dislocation  of  the  hip  is  often  only  the  last  stage  of  a 


544  mSLOCATIONS. 

paralysis  and  consequent  atrophy  of  the  pelvic-trochanteric  muscles.  This 
foetal  paraly.-is  leads  gradually  to  relaxation  of  the  ligaments,  and  this, 
often  only  after  the  lapse  of  time,  and  especially  after  the  children  have 
begun  to  walk,  and  by  the  action  of  the  weight  of  the  body,  to  dislo- 
cation (Verneuil,  1866).  This  theory  has  recently  (1878J  been  brought 
forward  again  by  some  of  Verneuil's  pupils  (Reclus,  Dalby),  and 
extended  to  congenital  dislocations  of  the  humerus  (Kirmisson). 

(Kronlein  in  this  fails  accurately  to  define  the  position  of  the  sup- 
porters of  this  theory.  Their  contention  is  not  so  ranch  that  congenital 
dislocations  are  thus  produced,  but  rather  that  some  so-called  congen- 
ital dislocations  originate  after  birth  in  a  paralysis,  and  are  mistakenly 
thought  to  have  been  congenital.  Reclus'  formulates  his  conclusions 
as  follows  : 

a.  From  the  group  of  so-called  congenital  dislocations  paralytic  dis- 
locations must  henceforth  be  withdrawn. 

b.  These  dislocations  follow  "amyotrophies,"  and  may  appear  at 
any  age,  although  they  have  rarely  been  seen  except  in  infancy, 

c.  For  their  production  two  conditions  are  necessary — atrophy  of  a 
muscular  group  ;  integrity  of  its  antagonists. 

d.  At  the  hi?>  the  iliac  dislocation  is  the  most  common.  It  is  due 
to  the  contraction  of  the  adductors,  which  is  unopposed  because  of  the 
atrophy  of  the  gluteal  and  pelvi-trochanteric  muscles.) 

6.  Congenital  dislocation  of  the  hip  is  due  in  most  cases — and  these 
should  he  regarded  as  typical — to  a  defect  of  formation  or  development^ 
wdiich  prevents  the  joint  from  assuming  the  normal  shape.  This  very 
generally  held  theory  was  presented  by  Palletta,  and  then  taken  up 
and  specially  developed  by  Schreger,  Dupuytren,  Breschet,  Von  Am- 
nion, and  others. 

Schreger  emphasizes  the  fact  that  so-called  congenital  defects  are  not 
produced  by  an  abnormal  change  in  pre-existing,  normally  formed  parts, 
but  are  due  to  defective  formation  or  arrest  of  development,  and  that 
is  especially  true  of  congenital  dislocations  of  the  hip.  Dupuytren  and 
Breschet  suggest  a  delayed  development  of  the  three  pelvic  bones  form- 
ing the  acetabulum.  Von  Ammon,^  in  his  remarkable  work,  expresses 
himself  very  clearly  concerning  congenital  dislocations,  which  he  terms 
dysarthroses  congenitce.  "  Even  if  their  external  appearance,"  he 
says,  "corresponds  somewhat  with  that  of  dislocations  acquired  after 
birth,  yet  in  their  method  of  formation  they  differ  essentially  from 
them,  and  they  also  have  only  the  slightest  resemblance  to  those  sec- 
ondary dislocations  that  follow  joint  disease.  ...  In  many  cases 
there  is  in  part  the  greatest  certainty,  and  in  part  the  greatest  proba- 
bility, that  the  affection  depends  upon  an  arrest  of  the  constituent  ])arts 
of  the  joint  at  an  earlier  foetal  stage  of  development.  According  to 
him,  a  congenital  dislocation  is  an  arrest  of  development.  The  ace- 
tabulum does  not  develop  into  the  usual,  symmetrically  rounded,  deep 
socket,  but  retains  its  earlier  saucer  shape  ;  while  the  head  of  the  femur, 
continuing  to  grow,  becomes  too  large  for  the  small  acetabulum,  and 
no  longer  suitable  to  lodge  in  it. 

'  Eeclus  :   Eevuc  Mensuelle  de  Med.  et  Chirurgie.  1S78,  p.  8S. 

^  Von  Amnion  :  Die  angeborenen  chirurgiscben  Krankheiteu  des  Menschen,  1842,  p.  9. 


CONGENITAL  DISLOCATIONS.  545 

Von  Ammon  recognized  not  only  this  typical  form  of  congenital 
dislocation  l)ut  also  the  other  varieties  that  had  been  described  hv  other 
authors,  and  quoted  cases  and  reproduced  drawings  in  illustration  of 
them.  So  far  as  the  typical  form  is  concerned,  hut  little  has  been 
added  since  his  time  to  our  knowledge  of  its  pathogeny,  and  that  little 
is  contained  in  a  })aper  published  by  Grawitz'  in  1878,  who,  l)y  micro- 
scopical examination  of  twelve  s])ecimens  of  congenital  dislocation  in 
seven  new-born  children,  showed  that  the  arrest  of  development  con- 
sisted in  a  failure  of  the  Y-cartilage  of  the  acetabulum  to  carry  on  the 
growth  of  one  or  all  of  the  three  segments  of  the  os  innominatum. 
He  found,  in  his  first  case,  for  example,  the  acetabulum  only  as  large 
as  that  of  a  foetus  of  about  the  fifth  month,  and  the  Y-cartilage  broader 
than  usual  because  of  diminished  ossification  of  the  three  adjoining 
bones,  the  pubis,  ischium,  and  ilium.  The  cartilage  was  hyaline  and 
vascularized,  and  with  normal,  elongated  cells  containing  one,  two,  or 
three  nuclei.  On  comparison  with  sections  of  a  normal  pelvis  of  the 
same  size,  a  striking  difference  appeared  at  the  junction  of  the  bone 
and  cartilage.  The  formative  zone  in  all  three  epiphyses  was  very 
imperfect,  its  cells  scanty  and  widely  separated,  and  the  zone  of  cells 
arranged  above  one  another  in  rows  adjoining  the  line  of  ossification 
was  not  one-third  as  wide  as  it  normally  is,  and  the  arrangement  of  its 
cells  was  irregular  and  broken.  In  some  of  the  cases  the  Y-cartilage 
was  centrally  interrupted  by  an  interposed  wedge  of  embryonal  adipose 
tissue.  On  the  other  hand,  the  appearances  in  the  femur  were  those  of 
normal  growth,  except  in  one  case.  In  no  case  was  there  premature 
ossification  of  the  Y-cartilage,  such  as  had  been  alleged  shortly  before 
by  Dollinger-  in  explanation  of  the  same  affection. 

The  conclusion,  I  think,  cannot  be  avoided  that  while  in  a  limited 
number  of  cases  dislocations  existing  at  birth,  especially  in  joints  other 
than  the  hip,  may  have  been  caused  by  traumatism,  abnormal  position 
of  the  limb,  or  paralysis  in  the  manner  alleged  by  various  writers,  }et 
in  the  great  majority  of  congenital  dislocations  of  the  hip  the  cause  is 
to  be  found  exclusively  in  arrest  of  development  of  the  acetabulum  by 
deficient  action  or  vitality  of  the  cells  of  the  Y-cartilage.  And  to  the 
testimony  in  support  of  this  opinion  furnished  by  anatomical  examina- 
tion of  specimens  may  be  added  that  drawn  from  clinical  observation, 
such  as  the  coexistence  of  other  deformities  due  to  arrest  of  develop- 
ment, the  frequency  of  double  and  multiple  dislocations,  the  inherited 
tendency  to  the  affection,  and  its  great  predominance  in  females. 

Many  of  the  congenital  dislocations  of  other  joints  than  the  hip  must 
also  be  regarded  as  due  to  defective  formation  of  the  corresponding 
bones,  but  the  defect  apparently  is  rather  a  malformation  than  the 
result  of  an  arrest  of  the  development  of  one  of  the  bones  constituting 
the  joint.  At  the  elbow,  in  dislocation  of  the  head  of  the  radius,  this 
bone  is  sometimes  found  relatively,  and  even  actually,  longer  than  the 
ulna.  In  a  specimen  taken  from  an  adult,  pictured  by  Iluiuphrv"* 
(Fig.    366),  of  dislocation  of  the   head   of   the    radius    forward    and 

'  Grawitz:  Vircliow's  Archiv.  1S78,  \i>\.  Ixxiv.  p.  1. 

^  DoUiiij^er :  Arch,  fiir  kliii.  Cliiriirpic,  ls77,  v<il.  xx.  ]!.  ()22. 

^Humphry:  Medico-Chirurgical  Transactions,  vpl-  xlv.  p.  296. 


546  DISLOCATIONS. 

upward,   there    was    anchylosis   of  the  joint   between    the    ulna   and 
humerus,  and  the  lower  third  of  the  ulna  of  the  other  arm  was  lacking. 

Fig.  366. 


Congenital  dislocation  oi  the  head   of  the  radius    upward  and  forward,  with   exaggerated 

growth  in  length. 

In  some  dislocations  of  the  knee  characterized  by  hyper-extension  of  the 
leg  upon  the  thigh  the  cause  appears  to  have  been  muscular  contraction. 

Of  the  other  etiological  varieties  that  have  been  asserted  to  exist, 
one  at  least  seems  to  have  been  proved  by  direct  examination  to  exist, 
that  in  whicS  the  dislocation  follows  distention  of  the  capsule  and 
ligaments  by  dropsy  of  the  joint  during  intra-uterine  life. 

Pathology. 

The  opportunities  for  studying  the  pathology  of  congenital  disloca- 
tions other  than  those  of  the  hip  have  been  so  very  rare,  and  the  study 
of  those  that  exist  has  been  m«ide  so  uncertain  by  the  doubtfulness  of 
the  diagnosis  in  some  and  the  difficulty  in  distinguishing  between 
primary  and  later  changes  in  others,  that  but  little  can  be  positively 
said  concerning  them.  In  studying  specimens  of  dislocation  of  the 
hip  it  is  necessary,  as  Gurlt  pointed  out,  to  distinguish  between  those 
obtained  from  very  young  children  who  have  never  walked,  those  from 
older  children  whose  growth  was  not  completed,  and  those  from  adults. 

Hip.  The  common  form  is  dislocation  upon  the  dorsum  of  the  ilium  ; 
the  only  exceptions,  and  they  are  extremely  rare,  are  upon  the  pubis 
and  into  the  obturator  foramen. 

In  the  new-born  child  with  a  dislocation  the  acetabulum  is  smaller 
and  flatter  than  normal,  and  is  continuous  by  its  flattened  posterior 
border  with  another  articular  surface  or  new  acetabulum  lying  above 
and  behind  the  original  one.  Usually,  too,  the  head  of  the  femur  is 
smaller  than  normal,  although  still  too.  large  for  the  acetabulum,  and 
the  neck  short  or  almost  absent ;  sometimes  the  head  and  neck  together 
have  a  conical  pointed  form.  The  ligamentum  teres  is  long  and  flat- 
tened, the  capsule  is  complete,  and  embraces  both  the  old  and  the  new 
acetabulum.     The  microscopical  changes  have  been  described  above. 

The  mechanism  of  the  alteration  seems  plain  ;  as  the  femur  and  its 
socket  originally  are  developed  out  of  one  continuous  strip  of  tissue,  they 
are  at  first  in  normal  relations  to  each  other,  but  when  the  development 
of  the  acetabulum  goes  on  more  slowly  and  imperfectly  than  that  of 
the  head  of  the  femur  the  latter  becomes  relatively  too  large,  and  being 
no  longer  firmly  held  in  place  it  is  gradually  drawn  backward  and 
upward  by  the  continuous  action  of  the  attached  nniscles,  the  corre- 
sponding edge  of  the  capsule  is  ])ressed  away  from  the  cotyloid  border, 
and  a  new  articular  surface  is  formed  at  the  point  where  the  head  of 


PATHOLOGY  OF  CONGENITAL  DISLOCATIONS. 


547 


the  femur  comes  to  rest.  Meanwhile,  the  defective  development  of  the 
original  acetabulum  persists,  and  its  variation  from  the  normal  is  ])rob- 
ably  still  further  increased  by  the  absence  from  it  of  the  femur.  The 
remaining  bones  and  the  muscles,  not  being  put  to  sufficient  use  to  feel 
the  effect  of  the  changed  relations  in  the  joint,  suffer  no  change  unless 
involved  in  some  associated  defect  of  development. 

Fig.  367. 


Innominate  bone  and  femur  from  a  case  of  congenital  dislocation  of  tlie  hip,  after  operation 
for  formation  of  a  new  acetabulum.    (Bradford.) 

But  as  soon  as  the  child  begins  to  wdk  this  change  in  tlie  relations 
of  the  bones  and  muscles  to  each  other  makes  itself  felt,  and,  as  the 
local  developmental  weakness  persists,  two  factors  are  now  at  work  to 
remove  the  condition  of  the  parts  still  further  from  the  normal.  TIh- 
acetabulum  by  its  continued  failure  to  sliarc  equally  in  the  gr()\\tli  of 


548 


DISLOCATIONS. 


the  pelvis,  becomes  relatively  smaller  and  more  deformed,  the  head  of 
the  femur  is  removed  still  further  from  it,  and  becomes  deformed  in 
consequence  of  its  irregular  bearings  upon  the  surface  of  the  ilium  ; 
the  ligameutum  teres  becomes  longer,  flatter,  and  thinner,  and  the  cap- 
sule thick  and  strong,  and  its  cavity  commonly  larger  than  usual.  As 
the  individual  advances  in  life,  and  after  puberty  has  been  reached,  the 
ascent  of  the  femur  is  finally  arrested,  partly  by  the  formation  of  a 

Fig. 368. 


Congenital  dislocation  of  hip;  girl,  three  years  old. 

socket,  and  partly  by  the  resistance  of  the  capsule  and  the  muscles. 
The  elements  of  sujiport  then  resemble  in  a  measure  those  sometimes 
found  with  ununited  fracture  of  the  neck  of  the  femur,  and  the  pelvis, 
instead  of  resting  directly  upon  the  femur,  is  suspended  from  it  by  the 
capsule,  ligaments,  some  of  the  pelvi-trochanteric  muscles,  and  even 
by  the  psoas-iliacus,  the  tendon  of  which,  instead  of  passing  down- 
ward, curves  around  the  brim  of  the  pelvis,  and  passes  upward,  out- 
ward, and  backward  to  the  lesser  trochanter,  \vhich  is  now  at  a  higher 
level  than  the  acetabulum. 

The  head  of  the  femur  may  be  separated  from  the  ilium  by  the  inter- 
posed capsule,  so  that  the  support  is  entirely  by  suspension,  and  there 
is  no  real  joint,  one  in  which  bony  surfaces  covered  with  cartilage  play 
upon  each  other ;  or  the  upper  and  posterior  attachment  of  the  capsule 
may  still  be  found  above  the  head  of  the  femur,  upon  an  overgrowth 
of  bone  springing  from  the  ilium  and  forming  the  upper  part  of  a  new 
socket,  the  remainder  of  which  is  constituted  by  the  body  of  the  ilium. 
The  latter  bone  sometimes  shows  at  this  point  an  overgrowth  of  bone, 
and  sometimes  a  depression  with  a  corresponding  thickening  on  the 
opposite,  inner  surface.  In  the  former  of  these  two  last-named  con- 
ditions, it  seems  probable  that  the  capsule  has  been  for  a  time  inter- 


PLATE  XXIX 


Congenital  Dislocation  of  the  Hip. 


PATHOLOGY  OF  CONGENITAL   DISLOCATIONS.  549 

posed  between  the  femur  and  the  ilium,  and  has  finally  disappeared  at 
this  point  under  pressure,  the  irritation  of  which  has  caused  the  out- 
growth of  bone  before  its  periosteum  has  in  turn  disappeared ;  in  the 
latter,  it  is  probable  that  the  attachment  of  the  capsule  has  been  pushed 
back  step  by  step,  leaving  a  bare  surface  of  bone  which  has  worn 
away  under  the  pressure  of  the  femur,  or  by  absorption  ;  while  the  asso- 
ciated irritation  has  led  to  a  conservative  thickening  on  its  other  side. 
The  communication  between  the  cavity  of  the  capsule  about  the  head 
and  the  acetabulum  is  through  a  narrowed  portion,  so  that  the  whole 
is  like  an  hour-glass.  The  old  acetabulum  is  narrow  and  elongated, 
running  upward  and  backward  ;  the  ligamentum  teres  perhaps  destroyed 
by  over-stretching. 

The  entire  pelvis  is  also  changed  in  shape  by  the  abnormal  direction 
of  the  pressure  to  which  it  is  subjected  in  walking.  If  the  dislocation 
is  unilateral,  the  crest  of  the  ilium  on  the  corresponding  side  is  carried 
inward,  and  the  tuberosity  of  the  ischium  outward,  the  horizontal 
branch  of  the  pubis  is  elongated,  and  its  direction  from  the  symphysis 
is  more  upward  and  backward  ;  the  anterior  superior  spine  of  the  ilium 
is  displaced  inward  and  backward,  and,  in  short,  the  entire  bone  under- 
goes a  change  in  shape  which  carries  its  centre  upward  and  backward, 
and  makes  its  lateral  surface  more  vertical. 

If  the  dislocation  is  double,  the  same  changes  are  found  on  both 
sides,  and  the  sacrum  is  more  sharply  curved. 

Symptoms  and  Diagnosis. 

The  symptoms  of  congenital  dislocations  differ  very  widely  from 
those  of  the  traumatic  variety,  and  not  only  by  the  absence  of  symp- 
toms peculiar  to  a  traumatism,  but  also  in  the  signs  recognizable  by 
palpation,  and  in  the  posture  and  mobility  of  the  limb.  In  general 
terras,  the  dislocation  is  to  be  recognized  by  an  examination  which 
determines  the  abnormal  position  and  altered  shape  of  the  correspond- 
ing ends  of  the  bones  and  the  range  of  motion,  and  by  consideration  of 
the  history  of  the  case. 

In  dislocations  of  the  hip  the  changes  are  very  likely  to  pass  unno- 
ticed until  after  the  child  has  begun  to  walk,  because  during  this  first 
period  they  are  usually  too  slight  to  attract  attention,  and  because  an 
examination  for  their  detection  is  not  likely  to  be  made  unless  it  is 
suggested  by  some  special  reason,  such  as  coexisting  malformations, 
or  the  history  of  similar  defects  in  other  members  of  the  family.  Even 
after  the  child  has  begun  to  walk,  the  defect  may  long  remain  unrecog- 
nized if  both  hips  are  affected,  because,  the  deformity  of  the  regions 
and  the  shortening  of  the  limbs  being  symmetrical,  they  do  not  attract 
much  attention.  Nevertheless,  the  changes  are  so  characteristic  that 
when  an  examination  is  made  the  diagnosis  cannot  well  remain  in  doubt. 

When  the  dislocation  is  unilateral  and  of  the  common  dorsal  variety, 
the  patient  limps  because  of  the  shortening  of  the  aft'ected  limb;  and 
for  the  same  reason  the  spine  shows  a  lateral  curvature,  which  can  be 
removed  by  supporting  the  foot  at  the  proper  height.  Because  of  the 
passage  of  the  head  of  the  femur  backward  and  upward  upon  the 


550 


DISLOCATIONS. 


ilium,  the  pelvis  is  tilted  so  that  its  upper  portion  is  directed  forward, 
and  a  marked  anterior  curvature  of  ,the  lower  portion  of  the  spinal 
column  is  produced,  which  disappears  when  the  patient  is  recumbent. 


Fig.  389. 


Fig.  370. 


Double  congenital  dislocation  of  the  hip. 

Inspection  and  manipulation  reveal  the  ascent  of  the  trochanter,  and 
the  head  of  the  femur  may  sometimes  be  distinctly  recognized.  The 
shortening  may  be  slight,  moderate,  or  very  great,  and  can  sometimes 
be  notably  increased  by  pressing  the  limb  upward.  Usually  the  glu- 
teal muscles  and  those  of  the  thigh  are  less  developed  than  those  of 
the  opposite  limb.  The  movements  of  the  joint  are  even  more  free 
than  normal,  except  perhaps  in  abduction,  but  when  vohmtarily  per- 
formed they  are  more  or  less  lacking  in  precision  and  firmness. 

When  the  dislocation  is  bilateral,  the  patient  walks,  not  with  a  limp, 


PROGNOSIS  AND  TREATMENT  OF  CONGENITALDISLOCATIONS    551 

but  with  a  peculiar  characteristic  waddle,  which  sometimes  amounts  to 
a  double  limp  and  makes  progression  difficult  and  uneertaiu.  The 
upper  part  of  the  pelvis  is  sharply  iucliued  forward,  producing  the 
same  lordosis  that  is  found  in  unilateral  dislocation,  but  without  the 
lateral  curvature  unless  there  is  a  difference  in  the  amount  of  the  defect 
on  the  two  sides.  The  arms  appear  unusually  long,  and  are  sometimes 
exceptionally  muscular.  Often  the  deformity  increases  with  time,  and 
the  patient  has  repeated  attacks  of  pain  ;  in  some  the  flexion  and  adduc- 
tion are  such  that  the  disability  is  great. 

At  other  joints,  such  as  the  shoulder,  elbow,  and  knee,  the  position 
of  the  bones  and  the  changes  in  their  shape  can  usually  be  easily  made 
out. 

Prognosis. 

The  prognosis  in  all  dislocations,  except  that  of  forward  dislocation 
(hyper-extension)  at  the  knee,  is  unfavorable,  so  far  as  reduction  is 
concerned. 

Treatment. 

Until  within  a  few  years  treatment  of  congenital  dislocations  of  the 
hip  was  practically  limited  to  palliative  measures,  such  as  a  thick  sole 
in  unilateral  cases  and  girdles  and  corsets  which  mechanically  opposed 
the  tilting  of  the  pelvis  and  the  ascent  of  the  trochanter  under  pressure, 
and  to  continuous  traction  maintained  for  months  and  followed  by  the  use 
of  traction-splints  in  both  unilateral  and  bilateral  cases.  By  these  means 
the  functional  condition  in  many  cases  appears  to  have  been  greatly 
improved,  and  much  of  the  improvement  to  have  been  maintained. 

Lannelongue  ^  sought  by  periosteal  irritation  to  create  a  buttress  of 
bone  upon  the  ilium  which  would  prevent  the  ascent  of  the  femur  after 
it  had  been  brought  down  by  traction.  He  produced  this  by  injection 
through  a  hypodermic  needle  of  twenty  drops  of  a  10  per  cent,  solution 
of  chloride  of  zinc  at  several  points  in  the  periosteum  close  above  the 
head  of  the  femur. 

Between  1890  and  1900  much  attention  was  given  to  operative  reduc- 
tion, or  fixation,  with  the  formation  of  a  new  acetabulum  or  enlarge- 
ment of  the  existing  one.  Since  then  this  has  largely  given  place  to  the 
so-called  "bloodless  operation"  of  which  Lorenz  is  so  well  known  an 
exponent.  The  literature  of  the  subject  is  abundant ;  the  reader  may 
advantageously  consult  articles  by  Dr.  E.  H.  Bradfoi'd  and  Dr.  T.  H. 
Myers  in  the  Annals  of  Surgery,  August,  1894,  and  by  Warbasse  in 
the  same,  June,  1895. 

The  earlier  operative  methods  exposed  the  capsule  by  a  lateral 
(Hoffa)  or  anterior  (Lorenz)  incision;  then  the  muscles  were  separated 
from  the  great  trochanter,  the  flexors  of  the  leg  divided  subcutaneously 
near  the  tuber  ischii,  the  adductors  near  the  pubis,  the  tensor  vagiuji^ 
femoris  by  open  incision,  and  the  rectus  femoris  through  the  first 
incision.  The  capsule  was  opened,  and  generiilly  detached  freel\'  from 
the  femur,  the  head  turned  out,  and  the  acetabulum  (>nlarged,  or  a  new 
one  made,  by  chiselling. 

1  Lannelongue:  La,  Semaiue  Med.,  December  30,  1891. 
39 


552  DISLOCATIONS. 

The  mortality  of  the  operation  was  quite  serious,  and  Lorenz^  has 
sought  to  do  away  with  the  division  of  the  muscles.  In  children  not 
over  five  years  old,  when  the  femur  can  be  drawn  well  down,  he  makes 
a  three-inch  incision  downward  and  outward  from  the  spine  of  the 
ilium,  divides  the  fascia  lata  along  it  and  also  backward,  divides 
the  capsule  in  front,  deepens  the  acetabulum,  and  puts  the  head  of  the 
femur  in  place.  In  children  between  six  and  eight  years,  when  the 
femur  cannot  be  brought  fully  down,  he  exposes  the  capsule  in  the 
same  manner  while  strong  traction  is  made  in  slight  abduction  against 
counter-traction  by  a  perineal  band,  and  after  division  of  the  capsule 
continuous  traction  until  the  head  is  brought  down.  In  cases  over 
nine  years  of  age,  with  marked  shortening  and  slight  mobility  down- 
ward, preliminary  traction  by  about  thirty  pounds  is  made  for  a  fort- 
night ;  then  continuous  forcible  traction  is  made  during  the  operation, 
and  the  capsule  is  divided  along  the  long  axis  of  the  neck  and  trans- 
versely near  the  ilium.  It  is  important  to  make  a  deep  excavation  with 
a  sharp  upper  margin  for  the  new  acetabulum.  The  limb  is  fixed  in  slight 
abduction  for  a  month,  and  then  massage  and  passive  motion  are  begun. 

Myers  recommends  for  old,  deformed,  or  painful  cases  Kirmisson's 
subtrochanteric  osteotomy,  or  Hoffa's  new  operation  of  removal  of  the 
head  and  neck  and  of  the  posterior  portion  of  the  capsule,  the  limb 
being  then  dressed  in  abduction  to  insure  close  contact  between  the 
trochanter  and  ilium. 

The  "  bloodless  method  "  (Paci  and  Lorenz)  consists  in  bringing  the 
head  opposite  the  acetabulum  by  forcible  extension  and  abduction  of  the 
thigh  and  retaining  it  there  for  several  weeks  by  a  plaster  spica.  For 
the  details  the  reader  may  consult  among  many  others  an  article  in 
the  N.  Y.  Med.  Journal,  Dec.  6,  1902,  p.  970.  It  is  undisputed  that 
many  excellent  functional  results  have  been  obtained  by  this  means, 
although  the  anatomical  conditions  remain  very  different  from  the 
normal.2  Joachimsthal  ^  showed  a  series  of  skiagrams  taken  one  or 
two  years  after  reduction  which  indicated  that  the  rim  of  the  acetabulum 
and  the  head  and  neck  of  the  femur  had  notably  increased  in  size. 

Congenital  dislocations  of  other  joints,  except  the  knee,  have  rarely 
received  any  treatment.  A  few  backward  dislocations  of  the  shoulder 
have  been  reduced  by  open  operation,  not  a  difficult  task  in  a  case  of 
my  own,  for  the  glenoid  fossa  was  well  formed  and  contained  within 
the  capsule  of  the  existing  joint.     (See  Chapter  XLIV.) 

In  dislocations  of  the  tibia  forward,  with  extreme  hyper-extension 
of  the  knee,  a  complete  cure  can  usually  be  effected  by  forcible  straight- 
ening of  the  limb  and  retention  for  a  short  time  by  splints. 

1  Lorenz:  Volkmann's  klin.  Vortrage,  1895,  No.  117,  and  Warbasse,  in  Annals  of  Sur- 
gery, June,  1895. 

2  Schede :  Centralblatt  fiir  Chirurgie,  1900,  p.  740. 

3  Joachimsthal :  Beilage  zum  Centralblatt  fur  Chirurgie,  1904,  p.  164. 


CHAPTER  XXXVI. 

SPONTANEOUS  DISLOCATIONS. 

These  are  dislocations  which  have  occurred  without  the  intervention 
of  a  recognizable  traumatism.  It  is  generally  held  that  some  of  the 
constituent  parts  of  the  joint  must  have  previously  been  so  altered  bv 
disease  as  to  facilitate  the  occurrence  ;  but  while  this  preliminarv  change 
does  doubtless  occur  in  the  great  majority  of  cases,  yet  there  is  reason 
to  think  that  spontaneous  dislocation  may  take  place  without  it,  through 
the  continuous  action  of  the  muscles,  when  the  limb  has  been  long  kept 
in  a  favorable  position.  Roser'  says  he  has  seen,  in  three  cases,  spon- 
taneous dislocation  of  the  hip  produced  by  the  reflex  muscular  contrac- 
tions excited  by  pressure  on  the  anterior  portion  of  the  spinal  cord  in 
patients  affected  with  kyphosis  and  consequent  paralysis.  The  dislo- 
cations occurred  slowly,  without  pain  or  swelling  of  the  region,  and 
without  a  sign  of  coxitis. 

The  term  "spontaneous,"  although  not  entirely  free  from  objection, 
is  in  general  use,  and  is  usually  preferred  to  others  that  have  been 
proposed,  such  as  pathological,  symptomatic,  inflammatory,  and  consecu- 
tive or  secondary.  Volkmann^  has  classified  them  according  to  the 
primary  changes  which  precede  and  facilitate  their  occurrence,  as  dis- 
locations, 1st,  by  distention;  2d,  by  destruction;  3d,  by  deformity; 
including  in  the  first  those  cases  in  which  the  joint  has  become  loose 
through  distention  of  its  capsule  and  ligaments  by  an  effusion  within 
it,  as  in  the  eruptive  fevers,  rheumatic  fever,  pyaemia,  and  the  puer- 
peral state  ;  in  the  second  those  in  which  the  shape  of  the  articular  end 
of  the  bone  has  been  changed  by  caries,  as  in  hip-joint  disease ;  and  in 
the  third  those  in  which  the  shape  has  been  changed  by  non-suppura- 
tive  disease,  as  in  arthritis  deformans.  To  these  may  be  added  a  4th 
class,  seen  mainly  in  adolescents,  in  which  the  shape  or  growth  of  the 
bone  has  been  so  modified  by  the  effects  of  pressure,  muscular  effort, 
or  gravity  that  a  permanent  displacement  takes  place ;  and  a  5th, 
"  paralytic "  or  "myopathic,"  in  which  the  dislocation  is  made  pos- 
sible by  paralysis  of  some  or  all  of  the  articular  muscles,  and  is  some- 
times effected  by  the  contraction  of  those  which  have  not  been  paralyzed. 

Although  the  propriety  of  applying  the  term  dislocation  to  a  change 
in  the  relations  of  two  bones  whose  corresponding  articular  ])orti()ns 
have  already  Vjcen  destroyed  has  been  questioned,  and  although  the 
change  of  place  does  not  come  within  the  definition  of  dislocation  ])re- 
viously  given,  and  although  the  condition  has  but  little  in  couimon 
with  traumatic  dislocations,  either  in  symptoms  or  in  treatment,  yet 
the  term  has  been  almost  universally  accepted  and  retained  in  ])refcr- 
ence  to  the  proposed  substitutes. 

1  Roser:  ('cntralhlatt  f.  Cliinirjric,  WH-->,  ji.  Hfi!). 

^  Volkmann :  Titha  and  Billroth's  tlhiriirgie,  vol.  ii.  part  ii.  p.  6;)H. 

( 553  ) 


554  DISLOCATIONS. 

In  all  these  varieties  the  immediate  cause  of  the  dislocation  is  the 
action  of  gravity  or  muscular  contraction. 

Dislocations  by  Distention  (Volkmann).  Concerning  the  pathology 
of  this  class  but  little  is  known  by  direct  examination,  because  of  the 
lack  of  autopsies,  but  the  clinical  history  is  well  established.  The 
joint  by  far  the  most  frequently  involved  is  the  hip ;  a  few  cases  have 
been  observed  at  the  shoulder  and  knee.  In  the  most  common  form 
the  course  of  the  symptoms  is  a  follows:'  A  patient  is  attacked  by 
febrile  articular  rheumatism  or  acute  mono-articular  arthritis;  the  pain 
is  great,  the  limb  assumes  a  faulty  position  ;  after  a  few  days  the  pain 
suddenly  ceases,  and  on  examination  the  region  of  the  affected  joint  is 
found  to  present  a  deformity  similar  to  that  which  characterizes  a  trau- 
matic dislocation.  If  the  condition  is  left  without  treatment,  the 
inflammation  comes  to  an  end  without  leaving  either  osteitis  or  suppu- 
ration, but  with  persisting  deformity  ;  if,  on  the  other  hand,  the  dislo- 
cation is  reduced,  the  deformity  is  thereby  entirely  removed,  and  in 
time  complete  recovery  is  obtained. 

In  other  cases  the  dislocation  takes  place  in  the  course  of  some  of 
the  eruptive  fevers  or  other  febrile  condition,  sometimes  without  pre- 
vious notable  pain  in  the  joint  and  without  the  knowledge,  at  the  time, 
of  the  patient.  William  W.  Keen  ^  collected  eighty-four  cases  of 
arthritis  occurring  as  a  complication  of  typhoid  and  typhus  fever,  in 
forty-three  of  which  dislocation  took  place,  forty  times  at  the  hip,  twice 
at  the  shoulder,  and  once  at  the  knee.  It  is  noteworthy  that  thirty- 
two  out  of  thirty-five  patients  were  under  twenty  years  of  age. 

It  thus  appears  that  these  dislocations  resemble  those  that  are  trau- 
matic in  their  sudden  occurrence,  the  absence  of  any  lesion  of  the 
bones,  and  the  possibility  of  immediate  and  permanent  reduction  with 
complete  restoration  of  function. 

The  presence  of  a  large  effusion  in  the  joint  and  the  elongation  of 
the  ligaments  have  been  assumed  by  all  observers,  and  the  actual  pres- 
ence of  an  effusion  of  some  amount  has  been  demonstrated  in  some  of 
the  exceptional  cases,  knee  and  shoulder,  where  such  demonstration 
was  possible.  On  the  supposition  of  this  effusion  and  of  the  relaxa- 
tion of  the  ligaments  produced  by  it,  the  production  of  the  dislocation 
has  been  explained.  Verneuil  has  further  called  attention  especially 
to  the  unopposed  contraction  of  certain  muscles  as  the  immediate 
cause. 

If  it  is  remembered  that  at  the  hip  these  dislocations  are  always 
backward  upon  the  dorsum  of  the  ilium,  and  are  preceded  by  the  long 
maintenance  of  the  limb  in  the  position  of  flexion,  adduction,  and 
inward  rotation  which  so  greatly  favor  the  occurrence  of  this  disloca- 
tion, and  that  the  muscles  are  stimulated  to  contraction  by  the  pain  of 
the  arthritis,  it  does  not  appear  improbable  that  this  contraction  is  not 
only  the  immediate  but  also  the  preponderant  cause  of  the  accident, 
and  that  the  arthritis  favors  it  not  by  overstretching  the  ligaments  but 
only  by  supplying  an  amount  of  liquid  that  removes  the  obstacle  created 
by  atmospheric  pressure.     These    two  conditions,  pain    and  eflPusion, 

1  Verneuil :  Bull,  de  la  Soc.  de  Chirurgie,  1883,  p.  781. 

2  Keeu  :  Surgical  Complications  and  Sequelje  of  Typhoid,  1898. 


SPONTANEOUS  DISLOCATIONS  555 

would  explain  why  the  dislocation  does  not  also  occur  in  the  course 
of  adynamic  diseases  in  which  the  limb  often  remains  for  a  long  time 
in  the  flexed  position. 

Certainly  the  theory  of  the  production  of  the  dislocation  hy  simple 
overdistention  is  incompatible  with  the  easy  reduction  and  mainte- 
nance of  the  reduction  noted  iu  several  cases.  It  was  unfortunate  for 
some  of  the  patients  that  their  surgeons  held  to  this  theory,  and  were 
logical  enough  to  refraiu  from  attempting  reduction  and  to  leave  the 
patients  permanently  crippled, 

A  few  cases  have  been  observed  in  which  an  acute  purulent  arthritis 
has  been  followed  by  dislocation ;  but  in  such  cases  it  is  always  pos- 
sible that  the  capsule  has  been  in  part  destroyed  by  the  suppuration. 

Paralytic  or  "  myopathic  "  dislocations  are  observed  especially 
at  the  shoulder.  The  humerus  is  held  up  and  kept  in  contact  with 
the  glenoid  cavity  by  the  tonicity  of  the  attached  muscles,  and  when 
this  tonicity  fails  the  weight  of  the  limb  causes  separation  of  the  bones 
and  subluxation  or  complete  dislocation.  The  cavity  of  the  joint, 
thus  enlarged,  is  filled  by  an  effusion,  but  this  effusion  is  the  conse- 
quence of  the  separation  rather  than  a  favoring,  precedent,  and  causa- 
tive condition,  for  it  is  presumably  drawn  from  the  surrounding  tissues 
by  suction,  just  as  oedema  appears  under  a  dry  cup. 

At  the  hip  they  are  produced  by  the  unopposed  contraction  of  those 
muscles  wdiich  have  not  been  paralyzed.  In  Roser's  three  cases  of 
spinal  caries,  mentioned  above,  the  dislocation  was  dorsal,  and  the 
immediate  cause  was  the  contraction  of  the  adductors  no  longer 
opposed  by  the  pelvic-trochanteric  muscles.  The  opposite  form,  dis- 
location upon  the  pubis,  due  to  paralysis  of  the  adductors  and  the 
consequently  unopposed  contraction  of  the  muscles  on  the  outer  side 
and  back  of  the  hip,  has  been  reported  by  Bradford  ^  and  Reclus.^ 

Another  variety  may  be  mentioned,  in  which  by  the  miequal  groidh 
of  parallel  honen,  the  tibia  and  fibula  or  the  radius  and  ulna,  one  of 
them  is  slowly  dislocated. 

Voluntary  dislocations  is  the  name  given  to  those  which  the  indi- 
vidual can  produce  and  reduce  at  will.  Those  in  which  the  pecu- 
liarity has  originated  in  a  previous  traumatic  dislocation  are  due  to 
ru])ture  of  some  of  the  ligaments  or  attached  muscles  and  have  been 
described  among  the  consequences  of  traumatic  dislocations ;  but  a 
number  of  cases  have  been  recorded  in  wdiich  this  cause  could  not  be 
invoked  in  explanation.      I  iiave  seen  two  such,  both  of  the  hip. 

Dislocations  by  destruction  and  dislocations  by  deformity  are 
of  less  practical  interest  to  the  surgeon  because  less  amenable  to  treat- 
ment, and  are  to  be  regarded  rather  as  incidents  in,  or  symptoms  of, 
other  diseases  than  as  morl)id  entities. 

In  the  former,  dislocation.s  by  dedructiou,  Volkmann  included  those 
dislocations  which  occur  in  the  course  of  chronic  tubercular  disease 
of  joints  or  as  a  consequence  of  acute  traumatic  supjjurative  arthritis. 
Frequent  examples  are  seen  at  the  hip  and  knee. 

In  consequence  of  the  destruction  of  the  articular  ligaments  or  of 

1  Bradford  :  Boston  Medical  and  Surgical  Journal,  1883,  vol.  cviii.  ]).  73. 
■•'  Eeclus :  Kevue  de  Med.  et  de  Chir.,  1878,  p.  176. 


556  msLocATiom. 

the  bones  themselves  an  abnormal  mobility  is  created  which  allows 
the  bones  readily  to  be  displaced  by  the  action  of  gravity  or  by  mus- 
cular contraction.  At  the  hip  this  displacement  is  usually  upward 
and  backward;  at  the  knee  the  well-known  subluxation  of  the  tibia 
backward  or  upward  is  produced  by  the  contraction  of  the  hamstring 
muscles,  or,  if  the  patient  lies  long  upon  one  side  and  the  destruction 
is  well  advanced,  the  displacement  may  be  lateral  to  the  distance  of  an 
inch  or  even  more. 

In  the  latter,  dislocations  by  deformity,  Volkmann  included  the  dis- 
locations which  occur  in  the  course  of  such  affections  as  the  morbus 
coxce  senilis  and  in  the  arthropathies  of  nervous  origin,  "Charcot's  dis- 
ease," in  which  the  articular  ends  of  the  bones  disappear  by  absorption 
without  suppuration. 

The  remaining  form  has  been  specially  studied,  so  far  as  I  know, 
only  by  Madelung,^  and  only  at  the  wrist ;  the  dislocation  was  always 
of  the  carpus  forward,  and  was  accompanied  by  marked  changes  in 
the  shape  of  the  radius  and  of  the  bones  of  the  first  row  of  the  carpus. 
The  cause  appeared  to  be  overexertion,  or,  rather,  prolonged  and  fre- 
quently repeated  exertion  in  patients  who,  presumably,  were  predis- 
posed to  the  change  by  defective  vitality  of  the  bones.  Volkmann 
includes  such  cases  under  the  general  head  of  disturbances  of  growth 
of  joints.^ 

1  Madelung :  Deutsche  Gessellschaft  fiir  Chirurgie,  1878,  p.  259,  aud  Arch.  f.  klin. 
Chir.,  vol.  xxiii. 

^  Volkmann  :  Loc.  cit.,  p.  692. 


CHAPTER  XXXVII. 

DISLOCATIONS  OF   THE  LOWER  JAW. 

Dislocations  of  the  lower  jaw  constitute  from  3  to  6  per  cent,  of 
all  dislocations  according  to  the  tables  in  Chapter  XXVII.  They 
may  be  bilateral  or  unilateral,  the  former  being  the  more  common,  in 
the  proportion  of  about  5  to  2  according  to  Malgaigne,  who  found  54 
bilateral  in  a  total  of  76  cases  which  he  collected.  Of  these  54,  31 
were  in  women,  and  this  greater  frequency  in  the  female  sex  is  univer- 
sally recognized.  The  injury  is  rare  in  infancy  and  old  age ;  it  has 
been  observed  in  patients  eighteen  and  seventy-two  years  old,  and  has 
been  caused  in  the  new-born  child  by  obstetric  manipulations. 

In  the  great  majority  of  cases  the  dislocation  is  forward,  the  condyle 
of  the  jaw  passing  in  front  of  the  articular  eminence  at  the  root  of  the 
zygoma.  A  few  instances  have  been  reported  of  double  or  single  dis- 
location backward  with  fracture  of  the  wall  separating  the  articular 
cavity  from  the  external  auditory  canal,  of  dislocation  upward  into 
the  cavity  of  the  cranium,  and  of  unilateral  dislocation  outward  wath 
or  |>erhaps  without  fracture  of  the  body  of  the  jaw.  These  are,  how- 
ever, entirely  exceptional  and  may  be  briefly  described  before  proceed- 
ing to  the  consideration  of  the  common  form. 

Dislocation  Backward.  ^ 

This  rare  injury  has  been  reported  in  thirteen  cases,  most  of  them 
women.  It  may  be  unilateral  but  is  usually  double.  The  pathology 
is  not  known  and  it  is  not  clear  where  the  condyle  lodges  or  how  it 
becomes  fixed  in  its  new  position,  possibly  by  interposition  of  the 
meniscus.  It  has  occurred  during  yawning  and  during  sleep,  once  by 
a  blow  upon  the  chin,  three  tiraes  by  an  inflammatory  or  rheumatic  con- 
traction of  the  temporal  muscle,  and  three  times  by  forcible  pressure  of 
the  jaws  together  and  the  act  of  swallowing.  In  Hacker's  case  it  oc- 
curred repeatedly  in  a  woman  who  had  long  suffered  from  frequently 
recurring  forward  dislocation. 

A  marked  symptom  is  inability  to  open  the  mouth,  the  lo^^■cr  jaw 
being  held  firmly  against  the  upper  and  a  little  behind  its  proper 
position.     Reduction  has  been  easy. 

Dislocation  Backward  with  Fracture. 

Dislocation  backward  with  fracture  of  the  posterior  wall  of  the 
articular  cavity  is  caused  by  great  violence  received  upon  the  chin  and 

1  Steiner :  Arch.  fiir.  klin.  Chir.,  1893,  vol.  45,  p.  622.  Hacker:  Beitrage  zur.  klin. 
Chir.,  1906-7,  vol.  52,  p.  748. 

(557) 


558 


nisLocATioys. 


acting  from  before  backward.  One  or  both  condyles  may  be  driven 
through  the  wall  into  the  external  auditory  canal,  breaking  the  bone 
and  lacerating  or  pushing  backward  the  outer  cartilaginous  portion. 
The  production  of  the  lesion  is  probably  easier  when  the  molar  teeth 
are  lacking  from  the  upper  or  lower  jaw,  or  if  tlie  mouth  is  partly  open 
when  the  blow  is  received.  The  symptoms  are  pain  in,  and  bleeding 
from,  the  ear,  immobility  of  the  jaw,  the  mouth  being  held  partly  open, 
and  displacement  backward,  as  shown  by  the  relations  of  the  front 
teeth  to  each  other.  The  absence  of  the  condyle  from  its  normal  posi- 
tion can  be  recognized  by  the  touch,  and  the  auditory  canal  is  seen  or 
felt  to  be  obstructed  by  the  displacement  of  its  anterior  wall. 

Dislocation  Upward. 

Le  Fevre^  reported  an  interesting  and  very  exceptional  case  in 
which  the  injury  was  caused  by  a  fall  from  a  heiglit,  the  blow  being 
received  upon  the  chin-  The  jaw  was  displaced  slightly  backward  and 
to  the  left,  the  teeth  were  close  together,  and  the  mouth  could  not  be 
opened.  Slight  bleeding  from  the  left'ear.  The  diagnosis  of  fracture 
of  the  condyle  was  made.  The  patient  was  dismissed  in  the  fourth 
week,  still  experiencing  difficulty  in  mastication  and  deglutition. 
Subsequently  he  suffered  from  violent  headache,  had  several  attacks 
of  convulsions,  and  died  about  six  months  after  the  receipt  of  the 
injury.  The  autopsy  showed  that  the  roof  of  the  glenoid  cavity  had 
been  fractured,  the  condyle  had  passed  into  the  cranium  between  the 
fragments,  the  neck  of  the  condyle  was  in  part  destroyed,  the  dura 
mater  was  extensively  inflamed  and  thickened,  and  there  was  a  large 
abscess  in  the  middle  lobe  of  the  brain. 

Dislocation  Outward. 

Eobert  ^  received  at  the  Hopital  Beaujon  a  patient  who  had  been  in= 
jured  by  the  passage  of  the  wheel  of  a  cart  across  the  right  side  of  his 
face.  The  chin  was  deviated  to  the  right,  and  the  mouth  was  held  open. 
The  left  condyle  of  the  lower  jaw  could  be  distinctly  felt  under  the  skin 
above  the  root  of  the  zygoma.  Greatly  surprised  at  this  displacement 
Eobert  sought  for  and  found  a  vertical  fracture  of  the  body  of  the  bone 
on  the  right  side  just  in  front  of  the  ramus.  The  left  coronoid  process 
remained  under  the  temporal  fossa,  the  sigmoid  notch  crossing  and  era- 
bracing  the  zygoma.  Reduction  was  made  by  pressing  the  left  ramus  out- 
ward until  the  condyle  was  freed  from  its  contact  with  the  upper  surface 
of  the  zygoma,  and  then  drawing  it  downward  and  inward  to  its  place. 

Neis '  reported  a  similar  case  and  collected  others. 

Dislocation  of  the  Jaw  Forward. 

This,  the  common  form,  is  usually  caused  by  muscular  action,  as  in 
laughing,  scolding,  yawning,  or  vomiting,  or  exceptionally  by  violence 

■'  Le  Fe^Te:  Journal  Hebdomadaire,  1834,  vol.  ill.  p.  333. 
2  Robert:  Archives  generales  de  Med.,  1845,  vol.  vii.  p.  44. 

■'  Neis :  Luxation  du  Maxillaire  inf.  en  haut  ou  dans  la  fosse  temporarle.     These  de 
Paris,  1879,  No.  252. 


DISLOCATIONS   OF  THE  LOWER  JAW.  559 

iu  widely  opeuiug  the  mouth  to  iutrodiice  some  large  object,  such  as  au 
apple  or  the  fist,  or  in  drawing  a  tooth,  or  by  a  blow  upon  the  jaw. 

In  order  to  understand  this  mechanism  it  is  necessary  to  recall  the 
construction  and  normal  action  of  the  joint.  The  lower  jaw  is  attached 
to  the  skull  by  a  synovial  capsule  which  is  strong  on  its  outer  side  (the 
external  lateral  ligament),  by  an  internal  lateral  ligament  not  in  imme- 
diate relations  with  the  joint  but  extending  from  the  spinous  process  of 
the  sphenoid  bone  to  the  margin  of  the  inferior  dental  foramen,  and  by 
the  stylo-maxillary  ligament,  a  strong  band  extending  from  the  styloid 
])rocess  of  the  temporal  bone  to  the  posterior  border  of  the  ramus  of 
the  jaw.  The  joint  is  occupied  by  an  intra-articular  cartilage  or  menis- 
cus which  overlies  the  upper  surface  of  the  condyle  and  accompanies 
it  in  its  normal  movement  forward  from  the  glenoid  cavity  to  the  emi- 
nentia  articularis  when  the  mouth  is  opened.  In  front  of  the  point  to 
which  the  condyle  thus  moves  forward  the  surface  of  the  eminentia 
articularis  is  inclined  slightly  u]iward  to  become  continuous  with  the 
nuich  narrower  lower  surface  of  the  zygoma.  The  fibres  of  the  mus- 
cles attached  to  the  ramus  which  close  the  mouth  run  upward  and  for- 
ward, and  only  those  belonging  to  the  deep  posterior  portion  of  the 
masseter  are  vertical  or  inclined  backward. 

Since  the  condyle  moves  forward  when  the  chin  descends,  the  centre 
of  motion  of  the  jaw  is  not  in  the  condyle,  but  at  a  point  below  it  at 
or  near  the  dental  foramen,  and  as  the  angle  of  the  jaw  is  at  the  same 
time  moved  backw'ard  the  axis  of  tlie  ramus  notably  changes  its 
relations  to  the  direction  of  the  fibres  of  the  masseter,  bringing  the  line 
of  the  posterior  ones  behind  the  centre  of  motion  where  their  contrac- 
tion tends  still  further  to  open  the  mouth  or  to  keep  it  open.  Still, 
the  cause,  wlien  muscular,  is  rather  to  be  found  in  the  excessive  action 
of  the  external  pterygoid,  aided  by  relaxation  of  the  external  lateral 
ligament,  which  latter  condition  is  produced  by  the  wide  opening  of 
the  mouth,  as  will  be  explained  more  fully  in  the  following  section. 

Pathology.  The  opportunities  directly  to  examine  cases  of  disloca- 
tion of  the  jaw  have  been  very  few,  and  experiments  upon  the  cadaver 
cannot  entirely  take  their  place,  but  it  appears  to  be  established  that 
Malgaigne's  opinion  that  the  condyle  did  not  advance  more  than  one 
or  two  millimetres  beyond  the  point  on  the  articular  eminence  which 
it  normally  reaches  is  not  correct,  but  that  the  advance  is  considerably 
greater.  In  an  autopsy  made  by  Demarquay  in  a  case  of  recurrent  dis- 
location the  condyle  was  in  front  of  the  transverse  part  of  the  zygoma  ; 
the  intra-articular  disk  was  behind  it.  It  also  appears  that  the  ruptiu'e 
of  the  capsule,  when  it  occurs,  takes  ])lace  in  front  between  the  menis- 
cus and  the  condyle,  but  sometimes  the  meniscus  accompanies  the  con- 
dyle without  rupture  of  the  capsule.  This  makes  the  persistence  of 
the  dislocation,  and  es])eclally  the  fixation  of  the  jaw,  difficult  to 
explain.  The  earliest  theory,  that  of  Petit,  the  contraction  of  the 
posterior  fibres  of  the  masseter,  is  generally  rejected  as  inade(iuate. 
Another,  also  advanced  by  the  earlier  writers  and  recently  brought 
forward  again  by  Nelaton  and  accepted  by  Malgaigne,  and  supjiorted 
by  at  least  one  specimen  which  is  figured  in  Malgaigne's  Atlas,  Plate 
XVII.,  fig.   1,   is  that  the  coronoid   process  becomes  engaged  under 


560 


DISLOCATIONS. 


the  malar  bone.  That  this  may  be  an  occasional  adjuvant  cause  must 
be  admitted  on  the  facts  presented,  but  that  it  is  not  the  sole  cause, 
and  probably  not  even  a  frequent  one,  is  proved  by  experiments  upon 
the  cadaver  which  have  shown  the  fixation  to  persist  after  removal  of 
the  coronoid  process,  and  by  the  fact  that  in  Nelaton's  specimen  the 
process  is  unusually  long. 

The  slightly  upward  inclination  of  the  anterior  surface  of  the  emi- 
nentia  articularis  against  which  the  displaced  condyle  rests  is  not  of 
itself  sufficient,  and  the  most  recent  theory,  suggested  by  Demarquay  ^ 
and  thoroughly  studied  by  Mathieu,^  that  the  return  of  the  condyle  is 
opposed  by  the  meniscus  beyond  which  it  has  passed,  seems  to  be  open 
to  the  objections  that  the  meniscus  is  so  freely  movable  backward  that 
it  would  be  readily  pushed  back  into  the  glenoid  cavity  by  the  return- 
ing condyle,  and  that  in  some  cases  it  accompanies  the  condyle  in  its 
excursion.  In  a  case  in  which  I  was  unable  to  reduce  I^  found  on 
exposing  the  joint  that  the  meniscus  had  been  torn  from  the  condyle 
and  was  so  lodged  in  the  glenoid  cavity  that  the   condyle  could  not 

Fig.  371. 


Diagrammatic  of  the  external  lateral  ligament  of  the  lo'wer  jaw.    A,  when  the  mouth  is  open ; 
B,  when  the.condyle  is  dislocated  forward. 

enter  it.  After  removal  of  the  meniscus  the  dislocation  was  easily 
reduced.  An  autopsy  reported  by  Perier*  of  a  case  of  recurrent  dislo- 
cation showed  absence  of  the  anterior  portion  of  the  meniscus  and 
lodgement  of  the  remainder  behind  the  condyle  after  reduction.  These 
prove  not  that  the  meniscus  is  the  cause  of  the  fixation,  but  that  it  may 
prevent  complete  reduction. 

The  cause  must  be  found,  I  think,  in  the  ligaments,  the  external 
lateral  and  perhaps  the  posterior  portion  of  the  capsule,  and  this  opin- 
ion is  supported  by  the  tenseness  of  the  lateral  ligament  observed  by 
Weber  ^  and  Maisonneuve^  upon  the  cadaver,  by  the  anatomical 
relations  of  the  parts,  and  also  by  the  experience  of  Kramer,'  who 
operated  upon  a  case  five  weeks  old  and  found  reduction  easy  after  he 
had  detached  a  portion  of  the  masseter  and  divided  the  tense  external 
lateral  ligament.  The  mechanism  of  its  action  I  conceive  to  be  as 
follows  :  The  external  lateral  ligament,  forming  the  anterior  part  of 

1  Demarquay :  Bull,  de  la  Soc.  de  Chirurgie,  1863,  vol.  iv.  p.  119. 

2Mathieu:  Arch.  gen.  de  Med.,  1868,  vol.  ii.  p.  129. 

sstimson:  Trans.  N.  Y.  Surg.  Soc,  Annals  of  Surgery,  March,  1898. 

*  Perier :  Bull,  de  la  Soc.  de  Chirurgie,  1878,  p.  222. 

5  Weber:  Handbuch  de  allg.  und  spec.  Chir.,  vol.  iii.  Abt.  1,  p.  288. 

fi  Maisonneuve :  Comptes-rendus,  Acad,  des  Sciences,  1862,  p.  654. 

'  Kramer :  Centralblatt  fiir  Chirurgie,  1901,  p.  369. 


DISLOCATIONS  OF  THE  LOWER  JAW.  561 

the  outer  portion  of  the  capsule,  extends  from  the  articular  eminence 
downward  and  backward  to  the  neck  of  the  condyle,  its  attachment  to 
the  eminence  being  posterior  to  the  point  at  which  the  lower  surface  of 
the  latter  begins  to  incline  upward.  This  ligament  (Fig.  371)  is  too 
short  to  allow  the  jaw  to  take  such  a  position  when  the  cond\de  is 
dislocated  forward  that  the  long  axis  of  the  neck  shall  coincide  with 
that  of  the  ligament.  When  the  mouth  is  widely  opened  the  liga- 
ment is  relaxed  by  the  approximation  of  its  points  of  attacliment,  and 
the  condyle  passes  forward  ;  then,  as  the  mouth  is  partly  chjsed,  the 
ligament  becomes  tense  before  the  condyle  has  moved  back  past  it,  and 
thus  its  further  movement  backward  is  prevented,  and  while  it  remains 
thus  displaced  any  force  that  tends  to  close  the  mouth  increases  the 
obstacle  to  replacement  by  making  the  ligament  more  tense  and  press- 
ing the  bones  more  firmly  together.  Such  a  force  is  naturally  and  con- 
stantly exerted  by  the  powerful  muscles  of  mastication,  stimulated  to 
contraction  as  they  are  by  their  forcible  elongation  and  the  pain  and 
anxiety  of  the  patient.  The  practical  inference  to  be  drawn  from  this 
explanation,  if  it  is  correct,  is  that  reduction  should  be  sought,  not  by 
crowding  the  body  of  the  jaw  downward  and  backward  by  jjressure 
upon  the  molar  teeth,  but  by  first  depressing  the  chin  if  possible, 
opening  the  mouth  wider,  so  as  to  relax  the  ligament,  and  then  press- 
ing the  condyle  backward  and  closing  the  moutii  as  it  passes  the  artic- 
ular eminence  on  its  way  back. 

Symptoms,  The  symptoms  of  bilateral  dislocation  forward  are  that 
the  mouth  is  held  open,  the  lower  jaw  immovable  and  projected  some- 
what forward ;  exceptionally,  only  the  projection  is  present,  and  the 
mouth  can  be  closed.  Speech  is  indistinct,  swallowing  difficult,  and 
chewing  impossible.  The  condyle  can  be  felt  in  advance  of  its  usual 
position,  and  a  depression  marking  the  empty  glenoid  cavity  can  be 
felt  in  front  of  the  ear.  The  checks  are  flattened,  and  the  saliva 
escapes  from  the  mouth.  The  masseter  and  temporal  muscles  are 
usually  tense,  and  the  upper  anterior  portion  of  the  former  is  raised 
by  the  coronoid  process. 

If  the  dislocation  is  unilateral  the  physical  signs  are  found  upon 
only  one  side,  the  chin  is  turned  to  the  opposite  side,  and  the  func- 
tional disability  is  less. 

Prognosis.  The  prognosis  is  favorable  both  as  regards  the  reduction 
of  the  dislocation  and  the  degree  of  disability  if  it  remains  unreduced, 
but  somewhat  unfavorable  in  that  recurrence  is  quite  probable.  If  it 
remains  unreduced  the  parts  appear  slowly  to  adjust  themselves  to  their 
new  relations  and  finally  to  permit  more  or  less  satisfactory  approxi- 
mation of  the  jaws  and  restoration  of  the  functions. 

Treatment.  Tlie  dislocation  is  one  which,  as  a  rule,  can  be  easily 
reduced,  one  indeed  in  which,  as  has  been  already  said,  reduction  has 
often  occurred  spontaneously.  Tiie  methods  employed  have,  perhaps 
in  consequence  of  this  fact,  been  numerous,  and  have  varied  greatly  in 
the  objects  aimed  at,  if  not  in  the  actual  mechanism  by  which  they 
have  accomplished  the  reduction.  It  can  be  shown,  I  think,  that  many 
of  the  methods  and  procedures  have  been  successful  not  because  they 
met  the  ideas  of  their  originators  concerning  the  obstacle  to  be  over- 


562  DISLOCATIONS. 

come,  but  because  they  overcame  or  avoided  another  obstacle  which 
had  not  been  recognized.  With  few  exceptions  the  aim  of  the  different 
methods  has  been  directly  to  depress  the  condyle  and  then  to  press  it 
backward,  and  this  aim  has  been  accomplished  by  direct  pressure  down- 
ward upon  the  molars,  or  indirectly  by  raising  the  cliin  after  having 
placed  a  wedge  between  the  back  teeth.  Those  who  found  the  obstacle 
in  the  hooking  of  the  coronoid  process  under  the  malar  bone  sought  to 
disengage  the  process  by  opening  the  mouth  more  widely,  and  then 
pressed  the  jaw  backward ;  while  others,  again,  pressed  the  bone  directly 
backward  by  placing  the  thumb  and  foretinger  of  one  hand  against  the 
coronoid  processes  and  then  elevated  the  chin  by  a  slight  blow  upon  it 
from  beneath.  It  is  noteworthy  that  some  of  the  gentlest  methods, 
some  which  approach  most  closely  to  that  which  I  conceive  to  be  the 
rational  method,  were  employed  by  the  earliest  surgeons,  even  by  Hip- 
pocrates, and  were  again  and  again  resumed  only  to  be  as  often  neglected 
and  forgotten.  Hippocrates's  method,  as  quoted  by  Malgaigne,  was  to 
lower  the  chin  a  little  in  order,  according  to  Galen,  to  free  the  coronoid 
process  from  the  malar  bone,  and  then  to  press  the  jaw  backward,  the 
patient  being  meanwhile  encouraged  to  relax  his  muscles  and  yield 
himself  as  completely  as  possible  to  the  effort  made  in  his  behalf. 
Although  the  intention  and  the  supposed  effect  was  to  free  the  coro- 
noid process,  yet  the  wider  opening  of  the  mouth  relaxed  the  lateral 
ligaments  and  facilitated  the  backward  propulsion. 

In  1862  Maisonneuve  again  revived  the  plan,  after  having  observed 
in  many  experiments  upon  the  cadaver  that  the  external  lateral,  spheno- 
maxillary, and  stylo-maxillary  ligaments  were  tense  and  that  after  their 
division  the  dislocation  could  be  reduced  with  great  ease.  He  ascribed 
the  fixation  to  the  pressure  of  the  condyle  against  the  zygoma,  a  press- 
ure "  maintained  by  the  combination  of  the  passive  resistance  of  the 
ligaments  and  the  energetic  contraction  of  the  elevator  muscles,"  and 
proposed  to  reduce  by  direct  backward  propulsion  after  diminishing 
the  pressure  by  opening  the  mouth  more  widely. 

It  is  unquestionable  that  in  this,  as  in  most  other  dislocations,  the 
obstacles  to  reduction  are  multiple,  and  that  contraction  of  the  muscles 
is  one  of  them,  and  that  it  especially  opposes  reduction  because  it 
directly  resists  the  attempt  to  place  the  bones  in  the  most  favorable 
position.  It  is  also  true  that  methods  of  reduction  are  habitually 
successful  which  are  not  based  upon  correct  anatomical  principles,  but 
nevertheless  those  principles  exist  and  are  the  same  as  in  other  dislo- 
cations ;  the  opposing  ligaments  must  be  relaxed,  and  the  bone  should 
follow  in  returning  to  its  socket  the  route  by  which  it  escaped  from  it. 
In  the  great  majority  of  cases,  as  has  been  said,  dislocation  takes  place 
while  the  mouth  is  widely  open  and  the  ramus  is  inclined  upward  and 
forward.  Theoretically,  then,  the  same  position  should  be  given  to  it 
as  a  preliminary  to  reduction,  and  although  the  opposition  of  the  mus- 
cles may  create  practical  difficulties  in  the  way  of  accomplishing  this 
which  will  prevent  its  universal  use  and  cause  other  methods  to  be 
preferred  in  the  simple  cases,  yet  in  all  difficult  cases  and  whenever 
this  opposition  has  been  annulled  by  ansestheisa  this  method  should  be 
employed  :  the  mouth  should  be  widely  opened  and  the  jaw  should  be 


DISLOCATIONS   OF  THE  LOWER  JAW.  563 

pressed  backward,  or  backward  and  slightly  downward.  The  press- 
ure may  be  conveniently  made  by  the  thumbs  placed  inside  or  outside 
the  mouth  against  the  anterior  edges  of  the  ascending  rami,  the  head 
of  the  patient  being  solidly  supported  behind,  or  by  pressing  with  the 
forefingers  against  the  front  of  the  ramus,  outside  the  mouth,  and  the 
middle  fingers  against  the  side  near  the  angle,  while  tlie  thumbs  and 
other  fingers  grasp  the  body  near  the  symphysis. 

In  the  method  by  forcible  depression  of  the  posterior  portion  of  the 
jaw  the  thumbs  may  be  used  alone  by  placing  them  upon  the  lower 
molar  teeth  and  pressing  downward  and  backward.  It  is  well  to 
guard  them  against  bruising  by  covering  them  with  cloths  or  leather, 
and  when  the  reduction  is  accomplished  they  should  be  rapidly  with- 
drawn or  slipped  to  the  outer  side  of  the  teeth  to  escape  being  bitten, 
an  accident  that  has  happened  to  several  surgeons  and  has  indeed  been 
the  cause  which  led  to  the  invention  of  other  procedures. 

Instead  of  direct  pressure  with  the  thumbs,  hinged  instruments 
have  been  used,  taking  their  bearings  upon  both  sets  of  molars. 

In  a  bilateral  case  five  months  old  in  which  other  measures  had  failed 
McGraw^  reduced  by  passing  through  an  incision  a  sharply  curved  strong 
steel  hook  into  the  sigmoid  notch,  and  with  it  drawing  the  mandible  forci- 
bly downward  and  backward  while  pressure  was  made  upon  the  chin.  In 
a  bilateral  case  thirteen  months  old  Brockway  ^  succeeded  by  exposing 
the  condyles  and  forcing  them  back  by  direct  pressure  on  them. 

Mazzoni  treated  an  irreducible  bilateral  dislocation  of  eight  mouths' 
standing  in  a  woman  twenty-seven  years  old  by  excision  of  both  con- 
dyles, with  an  excellent  functional  result. 

After  reduction  the  mouth  should  be  kept  closed  by  a  bandage  and  the 
patient  fed  on  soft  food  for  two  or  three  weeks.  It  is  not  unlikely  that  the 
marked  tendency  to  recurrence  so  commonly  observed  is  the  result  of  in- 
opportune use  of  the  jaw,  perhaps  also,  in  part,  of  the  favorite  method  of 
reduction  which  tends  to  elongate  or  rupture  the  lateral  ligaments. 

Annandale  ^  successfully  treated  two  cases  of  recurrent  dislocation  by 
opening  the  joint  and  suturing  the  meniscus  to  the  periosteum.  Irritating 
injections  into  the  peri-articular  tissues  have  also  been  employed. 

Pathological  or  Consecutive  Dislocations. 

Pathological  or  consecutive  dislocations  are  uncommon,  and  only  in  a 
few  cases*  has  the  condyle,  eroded  and  deformed  by  antecedent  inflam- 
mation, been  found  outside  its  cavity  and  sometimes  united  by  bony  union 
to  the  skull. 

Congenital  Dislocations. 

The  only  example  of  this  condition  of  which  I  have  found  mention,  if 
a  f(etal  monster  reported  by  Guerin  bo  excepted,  is  one  descril-)cd  by  R. 
W.  Smith."'  The  patient  was  a  congenital  idiot  who  died  at  the  age  of 
thirty-eight  years.  The  dislocation  existed  upon  the  right  side  and  was 
the  result  of  defective  develo]>ment  of  the  constituent  ])arts  of  the  joint. 

'■  McGraw :  Med.  Reeorcl,  1899,  vol.  Ivi,  p.  511. 

••^  Brockway:  Johns  Hopkins  Hosn.  Ball.,  May,  1890. 

'■'■  Annandale   Lancet,  1887,  i.  ]i.()411. 

^  GurltPath.  Anat.  der  Gelenkrankheiten,  p.  109,  Cases  5,  11,  15. 

5  R.  W.  Smith  :  Fractures  and  dislocations,  p.  273. 


564  DISLOCATIOXS. 

Dislocation  of  the  Major  Cornu  of  the  Hyoid  Bone 
(Dysphagia  Valsalvianaj. 

Under  this  title  Dr.  Franklin  Hazlehurst^  describes  a  personal  case 
and  studies  10  reported  cases.  With  reference  to  the  anatomy  he  says 
"the  attachment  of  the  major  cornu  of  the  hyoid  bone  to  the  superior 
cornu  of  the  thyroid  cartilage  through  the  medium  of  the  lateral  thyro- 
hyoid ligament  may  be  loose  or  firm;  the  attachment  of  the  major 
cornu  to  the  body  of  the  hyoid  sometimes  osseous  in  advanced  age, 
is  at  other  times  the  site  of  a  true  joint  with  a  synovial  membrane. 

Study  of  his  case  and  those  reported  he  says  "makes  it  seem  probable 
that  in  this  case  there  was  a  loose  articulation  of  the  major  cornu  with 
the  body  of  the  hyoid  bone,  or  a  loose  attachment  of  the  tip  of  the 
major  cornu  to  the  superior  horn  of  the  th^Toid." 

Direct  examination  of  the  part  had  been  made  in  only  one  case, 
after  death  by  pulmonary  tuberculosis;  it  showed  "a  sort  of  pouch 
which  answered  the  purpose  of  a  synovial  capsule,  and  embraced  the 
left  th^TO-hyoid  articulation.  It  was  filled  with  clear  fluid  and  had  a 
comparatively  large  rhomboid  sesamoid  bone  developed  in  the  outer 
wall  and  permitted  an  extraordinary  amount  of  motion." 

The  ages  of  the  patients  varied  from  seven  to  sixty  years,  and  in 
6  the  dislocation  took  place  repeatedly. 

In  2  cases  the  cause  was  violence  applied  to  the  side  of  the  neck, 
a  blow  with  a  stone,  choking  with  the  hand;  in  others  movements  of 
the  head  and  neck,  yawning,  coughing,  singing;  in  2  swallowing  a 
large  piece  of  food. 

The  symptoms  varied  from  mild,  especially  in  the  recurrent  cases, 
to  severe;  pain  in  swallowing  in  6  cases,  inability  to  swallow  even  water 
in  2,  marked  distress  in  4,  sensation  of  a  body  in  the  oesophagus  in  3. 
In  4  a  prominence  was  recognizable  by  sight  and  touch  on  the  side  of 
the  neck  between  the  jaw  and  the  sterno-mastoid  muscle.  In  one  the 
tip  of  the  great  cornu  could  be  seen  and  felt  distinctly  displaced  upward 
and  to  the  left,  on  a  level  with  the  angle  of  the  jaw,  and  the  entire  bone 
was  displaced  toward  that  side.  Reduction  was  accompanied  in  several 
cases  by  a  distinct  click,  in  all  it  was  followed  by  immediate  relief. 

In  many  of  the  cases  reduction  was  made  by  pressure  outward  with 
the  finger  in  the  pharynx  behind  the  tongue;  in  others  by  throwing 
the  head  back,  opening  the  mouth,  and  pressing  upon  or  manipulating 
the  region. 

1  Hazlehurst:  Bull.  Johns  Hopkins  Hosp.,  Nov.,  1912,  p.  344. 


CHAPTER  XXXVIII. 

DISLOCATIONS  OF   THE  VERTEBE^  AND  OF  THE    OCCIPUT 
FROM  THE  ATLAS. 

Classification  and  pathology,  secondary  changes,  etiology,  symptoms  and  diag- 
nosis, prognosis,  treatment — Dislocations  of  the  occiput,  atlas,  lower  six 
cervical  vertebrae,  dorsal  vertebrae,  lumbar  vertebrae. 

The  study  of  dislocations  of  the  vertebrse  is  closely  associated  with 
that  of  fractures  of  the  same  bones,  because  in  many  cases  the  differ- 
ential diagnosis  between  a  fracture  and  a  dislocation  cannot  be  made 
with  certainty,  and  because  the  associated  lesions  and  consequences  are 
the  same.  For  some  of  the  latter,  therefore,  the  reader  is  referred  to 
the  chapter  on  Fractures  of  the  Vertebrae. 

Concerning  the  frequency  of  dislocations  of  the  vertebrse  widely 
different  opinions  have  been  held  ;  some  (Delpech)  denying  even  the 
possibility  of  dislocation  without  fracture,  others  thinking  them  ex- 
tremely rare,  and  others,  again,  claiming  that  they  are  quite  common. 
The  most  notable  member  of  the  last  group  is  Porta,  who,  according 
to  Blasius,  observed  no  less  than  twenty-seven  cases  in  thirty  years. 
By  far  the  most  valuable  contribution  to  the  settlement  of  this  question, 
and  indeed  to  the  whole  subject,  is  the  monograph  of  Blasius,^  who 
collected  294  reported  cases,  of  which  185  were  dislocations,  37  dias- 
tases, and  in  72  it  remained  undetermined  to  which  of  these  two  classes 
the  lesion  belonged.  Although  an  autopsical  examination  was  made 
in  174,  yet  in  38  of  these  the  account  is  so  defective  that  the  variety 
and  seat  of  the  injury  cannot  be  determined;  and  in  only  172  of  the 
294  cases  can  these  details  be  said  to  have  been  established.  By  far 
the  most  common  seat  is  the  cervical  region,  then  the  dorsal,  and  last 
the  lumbar  region,  in  which  only  a  very  few  cases  have  been  observed. 
The  certain  cases  were  divided  among  the  decades  of  life  as  follows  : 
first.  7;  second,  17;  third,  25;  fourth",  15;  fifth,  14;  sixth,  6. 

The  diiference  of  opinion  above  mentioned  regarding  the  frequency 
of  the  occurrence  of  the  injury  in  general,  doubtless  depends  in  part 
upon  the  definitions  which  the  different  authors  have  adopted,  since 
some  accept  as  dislocations  only  those  cases  which  are  not  complicated 
by  fracture,  while  others  accept  also  those  in  which  an  associated  frac- 
ture can  be  rightly  deemed  unessential  to  the  production  of  the  dislo- 
cation. The  latter  view  is  in  harmony  with  the  classification  of  other 
dislocations,  and  will  be  adopted  here ;  a  dislocation  of  a  vertebra  being 

'  Blasius:  Die  traumatische  Wirbelverrenkungen,  in  Vierteljahrscliiift  fiir  prakt.  Heil- 
kuiide,  1869,  vol.  cii.  ciii. 

(  565  ) 


566  DISLOCATIONS. 

defined  as  an  injury  in  which  the  adjoining  articnkir  processes  on  one 
or  both  sides  have  been  partly  or  completely  separated  from  each  other, 
with  or  without  avulsion  of  portions  of  the  body  of  either  vertebra  or 
fracture  of  one  or  more  processes.  The  term  disatasis  is  applied  to 
those  dislocations  in  which,  the  intervertebral  disks  and  other  ligaments 
having  been  torn,  the  vertebrae  are  longitudinally  separated  from  each 
other  in  front  or  behind,  but  have  not  also  been  so  horizontally  dis- 
placed that  the  articular  surfaces  on  either  side  have  been  put  out  of 
line  with  each  other. 

The  terminology  employed  to  indicate  the  seat  and  variety  of  the 
displacement  has  also  varied  with  the  different  writers,  some  speaking 
of  the  upper,  others  of  the  lower,  vertebra  as  the  one  that  is  dislocated, 
while  others  have  sought  to  avoid  misunderstanding  by  using  such  a 
phrase  as  "  dislocation  of  the  fifth  upon  the  sixth."  The  latter  form 
can  be  advantageously  employed  in  the  report  of  cases,  or  whenever 
any  doubt  might  arise  as  to  the  meaning,  but  it  will  be  convenient 
here  to  follow  the  more  general  practice,  and  speak  of  the  upper  ver- 
tebra as  the  one  that  is  dislocated,  and  of  the  direction  and  character 
of  its  displacement  as  those  of  the  dislocation. 

Classification  and  Pathology.  The  relations  of  the  vertebrae  to  each 
other  are  so  complex,  and  the  combinations  of  different  directions 
which  the  displacements  may  present  are  so  variable  and  numerous, 
that  a  classification  of  the  varieties  based  upon  these  directions  is  not 
only  very  complicated,  but  it  also  fails  to  offer  comparative  advantages 
sufficient  to  compensate  for  its  complexity.  The  classification  made 
by  Hueter,  according  to  the  character  of  the  movement  or  the  direction 
of  the  force  which  produces  the  dislocation,  is  simple,  and  at  the  same 
time  indicates  the  main  features  of  the  displacement  and  suggests  the 
proper  method  of  reduction.  It  fails,  however,  to  distinguish  between 
the  varieties ;  and,  therefore,  while  adopting  it,  it  has  appeared  desir- 
able also  to  use  in  connection  with  it  other  terms  indicative  of  special 
features. 

The  provisions  for  normal  motion  between  adjoining  vertebrae  consist 
in  the  elasticity  and  compressibility  of  the  intervertebral  disks  between 
the  bodies  and  in  the  articulations  placed  just  behind  them  upon  the 
arches.  The  normal  range  of  motion,  though  varying  in  the  different 
portions  of  the  column,  is  at  best  slight,  and  can  be  referred  in  the 
main  to  two  axes  for  each  pair,  one  of  which  lies  in  the  median  plane 
and  passes  through  the  centre  of  the  disk  from  behind  forward,  with 
an  inclination  downward  of  its  anterior  end  which  is  slight  in  the 
lumbar  and  lower  dorsal  regions,  more  marked  in  the  upper  dorsal, 
and  greatest  in  the  cervical  regions.  The  other  axis  is  a  horizontal 
transverse  one,  passing  througli  the  posterior  part  of  the  disk. 
Motion  about  the  first  axis  produces  a  lateral  bending  of  the  col- 
umn, and,  in  the  cases  in  which  the  axis  is  inclined  downward  and 
forward,  with  this  motion  must  be  associated  a  rotation  of  the  upper 
vertebra  by  which  the  anterior  surface  of  its  body  is  turned  to  the  side 
toward  which  the  column  is  inclined;  and  the  greater  the  inclination 
of  the  axis,  the  more  marked  is  this  associated  rotation.     The  move- 


DISLOCATIONS  OF   THE   VERTEBRM. 


567 


Fig.  372. 


raent  is  arrested  by  the  contact  of  the  margins  of  the  adjoining-  articular 
surfaces  with  their  bases  on  the  concave  side,  and  if  it  persists  bevond 
this  point  dislocation  is  produced,  the  opposite  inferior  articular  surface 
of  the  upper  vertebra  being  raised  above  the  one 
with  which  it  articuhites  by  the  lateral  bending, 
and  being  carried  forward  by  the  rotation.  To 
these  dislocations  Hueter  gives  the  name  disloca- 
tions by  abduction  or  rotation. 

Motion  about  the  other,  transverse,  axis  pro- 
duces a  bending  forward  (or,  to  a  less  degree, 
backward)  of  the  column,  during  which  the  ante- 
rior portion  of  the  disk  is  compressed,  the  pos- 
terior portion  stretched,  and  both  inferior  articular 
surfaces  of  the  upper  vertebra  are  moved  upward 
and  forward  along  tlie  superior  articular  surfaces 
of  the  underlying  vertebra.  The  movement  is 
checked,  when  its  normal  limit  is  reached,  by  the 
ligaments  of  the  joints  and  arches,  and,  if  these 
yield,  a  dislocation  is  produced,  in  which  the 
inferior  articular  processes  of  the  upper  vertebra 
pass  forward  and  in  front  of  those  with  which  they 
articulate — dislocation  by  flexion. 

Under  the  first  head,  dislocations  by  abduction, 
are  to  be  included  the  complete  or  incomplete  uni- 
lateral dislocations  forward  or  backward,  and  the 
bilateral  dislocations  in  opposite  directions,  de- 
scribed as  distinct  forms  under  these  names  by 
Blasius,  all  of  which,  with  one  exception  (the 
unilateral  dislocation  backward)  represent  only 
different  degrees  of  the  same  displacement.  In- 
stead of  being  entirely  separated  from  each  other, 
the  articular  surfaces  may  remain  in  contact  at 
their  edges.  If  the  displacement  is  somewhat 
greater,  the  inferior  process  of  the  upper  vertebra 

passes  further  forward,  and  sinks  into  the  notch  lietween  the  body  and 
the  superior  articular  process  of  the  lower  vertebra  (complete  unilat- 
eral dislocation.  Fig.  373),  and  at  the  same  time  the  inferior  process  on 
the  opposite  side  may  be  carried  backward  by  the  movement  of  rotation 
(bilateral  dislocation  in  opposite  directions).  Tiie  unilateral  dislocation 
backward,  of  which  Blasius  refers  to  a  few  examples  exclusive  of  those 
of  the  occiput  upon  the  atlas,  may,  I  think,  be  attributed  to  the  same 
mechanism,  the  displacement  being  effected  in  consequence  of  the 
yielding  of  the  ligaments  of  the  joint  on  the  side  toward  which  the 
body  is  bent,  instead  of  on  the  opposite  side  as  in  the  other  cases. 
In  a  case  observed  l)y  Cloquet,  and  briefly  mentioned  by  Blasius, 
the  second  lumbar  vertebra  was  dislocated  in  this  manner,  the  dis- 
location being  complicated,  but  unessentially,  by  fracture  of  the 
body  and  arch  of  the  vertebra;  all  the  processes  were  uninjured. 
The  patient  survived  several  years,  and  the  condition  of  the  j)arts  was 
40 


Direction  of  tlie  median 
axis  in  the  different  sec- 
tions of  the  spinal  col- 
umn.   (Henke.) 


568     ,  DISLOCATIONS. 

determined  by  autopsical  examination.  Under  the  second  head,  disloca- 
tions by  flexion,  are  included  bilateral  dislocations  forward  or  backward. 
The  force  continuing  to  act  after  the  normal  limit  of  forward  flexion  of 
the  column  has  been  reached,  the  ligamenta  subflava  are  ruptured,  and 
the  posterior  portion  of  the  intervertebral  disk  is  torn  or  separated  from 

Fig.  373. 


Complete  unilateral  dislocation  by  rotation  or  abduction ;  cervical  vertebra.    (Konig.) 

the  vertebra  with  or  without  avulsion  of  a  portion  of  the  bone ;  the 
articular  processes  of  the  upper  vertebra  lodge  in  front  of  those  of  the 
lower  in  the  notches.  Sometimes  the  processes  do  not  pass  entirely 
beyond  each  other,  but  remain  in  contact  at  their  extremities  ;  and 
sometimes,  the  movement  being  accompanied  by  slight  rotation  of  the 
vertebrae  upon  each  other,  one  articular  process  is  displaced  further 
forward  than  the  other.  The  lumen  of  the  vertebral  canal  may  be 
seriously  encroached  upon  in  this  dislocation,  and  its  contents  injured 
by  compression  against  the  upper  edge  of  the  body  of  the  lower  ver- 
tebra. 

The  mechanism  of  the  double  dislocation  backward,  of  which  a  few 
cases  have  been  accurately  observed,  has  not  been  demonstrated,  but 
the  possibility  of  its  production  by  extreme  dorsal  flexion  of  the  column 
is  such  that  it  may,  provisionally  at  least,  be  placed  in  this  class.  The 
motion  is  arrested  by  bony  contact  at  the  arches,  and  by  the  interver- 
tebral disks,  the  efficiency  of  whose  resistance  is  increased  by  their 
greater  distance  from  the  fulcrum  about  which  the  rupturing  move- 
ment must  turn.  It  is  interesting  to  note  that  in  a  case  reported  by 
Stanley,^  dislocation  backward  of  the  fifth  cervical  vertebra,  the  upper 
five  vertebrae  were  firmly  united  together  by  bony  fusion.  The  dis- 
placement was  so  great  that  the  body  of  the  fifth  rested  upon  the 
laminae  and  spinous  process  of  the  sixth.  The  additional  leverage 
created  by  this  anchylosis  may  be  invoked  as  an  argument  in  favor  of 
the  theory  of  production  by  dorsal  flexion. 

Transverse  dislocation  has  been  diagnosticated  in  several  cases,  but 
the  only  one  in  which  sufficient  anatomical  proof  has  been  obtained  is  the 
following  mentioned  by  Charles  Bell.^  A  child  was  run  over  by  a  stage- 
coach and  died  of  croup  thirteen  months  later.     The  last  dorsal  ver- 

1  Stanley :  Edinburgh  Medical  and  Surgical  Journal,  October,  1S41,  p.  404. 
'  Bell;  Injuries  to  the  Spine  and  Tbigh-bone,  1824,  p,  25. 


DISLOCATIONS   OF    THE   VERTEBRA.  569 

tebra  was  found  completely  displaced  to  the  left  side  of  the  first  lum- 
bar with  slight  chipping  of  the  bone.  The  articulation  between  these 
vertebrae  is  of  such  a  character  that  this  form  of  dislocation  would 
seem  impossible  without  a  fracture  of  the  articular  processes,  and  prob- 
ably it  may  still  probably  be  deemed  so  except  in  a  child.  The  same 
anatomical  conditions  exist  in  the  lumbar  vetebrse,  but  in  the  dorsal 
and  cervical  regions  the  articular  surfaces  look  backward  and  forward 
or  are  only  slightly  inclined  to  one  side,  consequently  this  form  of  dis- 
location must  there  be  regarded  as  possible. 

In  the  greater  part  of  the  dorsal  region  it  would  necessarily  be  asso- 
ciated with  dislocation  of  the  vertebral  end  of  the  corresponding  rib. 

In  all  the  clinical  cases  quoted  by  Blasius,  with  one  exception,  the 
cervical  vertebrae  were  concerned,  and  he  says  that  the  correctness  of 
the  diagnosis  is  very  doubtful  in  all. 

The  main  groups  and  varieties,  then,  are  as  follows  : 
Dislocations  by  flexion,  ventral  or  dorsal. 
Bilateral  forward. 
Bilateral  backward. 
Dislocations  by  abduction  or  rotation. 

Unilateral  forward      1  ,  ,         .  ,  , 

TT  .1  ^      11      1         J    }  complete  or  incomplete. 
Unilateral  backward  J  ^  ^ 

Bilateral  in  opposite  directions. 

Transverse.(?) 

The  associated  lesions  comprise  rupture  of  the  various  ligaments, 
muscles,  bloodvessels,  and  nerves,  fracture  of  the  bones,  and  injuries 
of  the  spinal  cord  and  its  membranes,  and  those  later  changes  which 
may  be  induced  by  the  primary  ones. 

The  intervertebral  disk  is  always  ruptured  or  torn  away  from  one  or 
the  other  vertebra,  and  this  rupture  or  separation  is  almost  invariably 
complete,  and  is  accompanied  by  the  avulsion  of  larger  or  smaller 
fragments  of  the  bone.  In  one  or  two  cases  the  disk  appears  to  have 
been  crushed. 

The  capsular  ligament,  on  one  or  both  sides  according  to  the  char- 
acter of  the  displacement,  is  always  torn.  The  anterior  2ind  postei'ior 
ligaments  are  either  torn,  wholly  or  in  ]iart,  or  stripped  from  their 
attachments  to  the  bodies  of  the  vertebrae,  sometimes  bringing  with 
them  in  the  latter  case  portions  of  the  bone.  The  ligamods  between 
the  lamince  and  the  spinous  pjrocesses  are  either  torn  or  put  upon  the 
stretch,  and  those  between  the  transverse  processes  were  torn  in  the 
only  reported  case  found  by  Blasius  in  which  their  condition  was  men- 
tioned. Instead  of  rupture  of  the  ligaments  fracture  of  the  processes 
to  which  they  are  attached  may  occur,  and  various  other  fractures  of 
the  adjoining  processes  or  of  more  distant  parts  are  frc(|uently 
observed. 

The  surrounding  and  the  attached  muscles  may  be  torn  by  the  dis- 
placement or  by  the  direct  action  upon  them  of  the  dislocating  vio- 
lence. 

The  veins  coming  from  the  bodies  of  the  vcrtebne  and  those  of  (lie 
meninges  of  the  cord  are  so  large  and  their  relations  with  the  l)ones 


570  DISLOCATIONS. 

and  ligaments  are  so  close  that  hemorrhage  is  always  free  and  some- 
times very  profuse. 

In  dislocations  of  the  cervical  vertebrae  the  vertebral  arteries  so 
commonly  escape  injury  that  the  possibility  of  their  rupture  has  been 
denied,  but  in  a  case  received  into  St.  Thomas's  Hospital  ^  the  verte- 
bral artery  was  found  to  have  been  torn  and  a  large  amount  of  blood 
to  have  escaped  into  the  vertebral  canal  and  among  the  muscles. 
Blasius  admits  this  case  into  his  list,  although  all  the  processes  of  the 
fourth  vertebra  were  broken. 

The  nerve  trunks  at  their  point  of  emergence  through  the  interver- 
tebral foramina  may  be  compressed  or  torn  on  one  or  both  sides 
between  the  articular  process  of  one  vertebra  and  the  body  or  pedicle 
of  the  other ;  and  in  the  lumbar  or  lower  dorsal  regions  the  nerves 
constituting  the  cauda  equina  have  repeatedly  been  found  torn  across 
or  compressed  between  the  body  and  laminae  of  the  adjoining  vertebrae. 

The  spinal  cord  and  its  membranes  may  entirely  escape  injury,  and 
if  injured,  the  lesion  may  present  any  grade  between  simple  compres- 
sion and  complete  rupture.  The  injury  may  be  caused  by  pressure  of 
the  bone  against  the  cord  or  by  the  direct  elongation  of  the  latter. 
All  the  lining  membranes  may  be  torn,  entirely  across  or  only  in  part, 
or  one  of  them  alone  may  be  ruptured.  Their  rupture  is  necessarily 
accompanied  by  the  extravasation  of  blood,  usually  profuse,  between 
the  dura  and  the  bone  and  amid  the  meninges.  Occasionally  an  extra- 
vasation of  blood  has  been  found  within  the  cord  itself;  thus,  in  a 
case  reported  by  Martini,^  one  of  diastasis  between  the  fourth  and 
fifth  cervical  vertebrae,  in  which  there  was  complete  rupture  of  all  the 
ligaments  and  separation  to  such  an  extent  that  the  finger  could  be 
passed  between  the  bones,  the  meninges  were  not  torn,  and  the  only 
lesion  found  in  the  cord  was  a  clot  three  centimetres  long  in  its  centre 
and  involving  also  the  cortical  substance.  A  similar  case  has  recently 
been  reported  by  Quenu.^  It  is  worthy  of  note  that  in  three  reported 
cases*  in  which  extensive  paralysis  was  present  the  autopsy  failed  to 
show  any  lesion  of  the  cord,  and  that  in  others  there  has  appeared  to 
be  no  fixed  relation  between  the  extent  of  the  paralysis  and  the  ana- 
tomical lesions  found  in  the  cord.  Probably  these  three,  and  the  two 
preceding,  were  cases  of  haematomyelia.  In  other  cases  the  cord  has 
been  found  torn  while  the  ligaments  have  been  only  slightly  injured. 

The  analysis  made  by  Blasius  to  determine  the  relative  frequency 
and  severity  of  injury  to  the  cord  in  the  different  forms  and  at  differ- 
ent seats  of  dislocation  shows  that  the  danger  is  greatest  in  disloca- 
tion of  the  lower  cervical  vertebrae,  the  fifth  and  especially  the  sixth, 
although  even  there  the  cord  may  entirely  escape  injury.  In  the 
variety  which  he  terms  "  unilateral  forward  "  (dislocation  by  abduction 
or  rotation)  the   danger   is   less   than   in  the  "  bilateral   forward "  or 

1  Medico-Chirurgical  Eeview,  1831,  vol.  xiv.  (18  of  aualyt.  series),  p.  227. 

''■  Martini:  Schmidt's  Jahrbiicher,  1861,  vol.  ex.  p.  195. 

•^  Quenu  :  Le  Progres  Medical,  February  27,  1887. 

*Colboriie:  Provincial  Medical  and  Surgical  Journal,  vol.  ii.  p.  50;  Hafner:  Zeit- 
schriftfiir  Wiuidarztc  und  Geburtshelfer,  1856,  vol,  ix.  p.  249;  and  Porta:  Delia  lussa- 
zioni  delle  vertebre,  1864,  quoted  by  Blasius, 


DISLOCATIONS  OF   THE   VERTEBRA.  571 

"backward"  (dislocation  by  flexion);  in  7  autopsies  the  cord  was 
found  injured  in  6,  and  of  45  cases  observed  clinically,  all  of  the  neck, 
in  9  there  was  evidence  of  injury  or  compression  of  the  cord,  which 
disappeared  in  5  and  was  folhjwed  in  4  by  inflammatory  and  softening 
processes  in  the  cord.  The  variety  which  he  terms  '^  bilateral  in  oppo- 
site directions"  appears"  particularly  free  from  this  danger;  in  the 
few  cases  he  collected  paralysis  was  exceptional  and  temporary.  Of  8 
cases  of  bilateral  dislocation  backward  examined  post  mortem,  the 
cord  was  uninjured  in  2,  and  more  or  less  severely  injured  in  6 ;  of  6 
clinical  cases,  in  3  there  was  no  paralysis,  and  in  3  the  paralysis  was 
temporary.  Of  52  cases  of  bilateral  dislocation  forward,  the  cord  was 
uninjured  in  17,  and  was  injured  seriously  and  irreparably  in  11  ;  in 
the  remaining  24,  either  recovery  followed  or  a  distinction  cannot  be 
made  between  the  effects  of  the  mechanical  violence  inflicted  upon  the 
cord  by  the  dislocation  and  those  of  the  later  mflammatory  and  nutri- 
tive changes.  It  must  be  remembered  that  in  most  of  the  clinical 
cases  our  knowledge  of  the  exact  character  of  the  lesion  of  the  skel- 
eton is  defective.  It  has  recently  been  shown  that  hemorrhage  within 
the  gray  matter  of  the  cord,  hcematomyelia,  may  be  produced  by  a 
temporary  diastasis  of  the  lower  cervical  and  upper  dorsal  region,  and 
even  without  recognizable  injury  of  the  column  or  its  ligaments.  And 
yet  there  is,  at  first,  a  motor  paralysis  which  may  be  as  complete  as 
after  transverse  rupture  or  crush  of  the  cord.  (See  Chapter  XI., 
Fractures  of  the  Vertebrae,  pp.  166, 168.) 

Blasius  ^  summarizes  the  analysis  as  follows  :  in  no  form  of  disloca- 
tion is  injury  of  the  spinal  cord  a  necessary  consequence ;  such  injury 
is  less  to  be  expected  in  unilateral  dislocation,  and  in  unilateral  dislo- 
cation forward  of  the  cervical  vertebra  it  is  always,  or  almost  always, 
only  a  simple  compression  without  crushing  ;  in  bilateral  dislocation 
backward  or  forward,  either  of  the  dorsal  or  cervical  vertebrae,  the 
cord  is  exposed  to  more  serious  lesions  and  seldom  escapes  entirely 
uninjured,  and  when  the  displacement  is  forward  the  cord  is  mechan- 
ically affected  in  most  cases,  but  the  cases  of  severe  injury  are  fewer 
than  those  in  which  all  injury  is  escaped  ;  finally,  the  danger  is  least 
in  bilateral  dislocation  in  opposite  directions. 

Secondary  Changes.  When  the  patients  survive  for  a  sufficient 
length  of  time  the  signs  of  a  more  or  less  acute  inflammatory  reaction 
appear.  While  this  reaction  is  not  frequent  or  usually  severe,  yet 
in  a  number  of  cases  pus  has  been  found  in  the  meninges  and  even 
in  the  centre  of  the  cord  itself.  The  cord  may  be  slightly  soft- 
ened and  changed  in  color,  or  it  may  be  reduced  to  pulp,  and  this 
change  may  involve  only  the  portion  corresponding  to  the  dislocated 
vertebra  or  it  may  extend  to  a  greater  or  less  distance  above  and  below. 
It  is  probable  also  that  other  changes  observed  after  fracture  of  the 
vertebrae,  such  as  extensive  suppuration  within  the  pia  and  the  substi- 
tution of  fibrous  tissue  for  the  nervous  elements  of  the  cord,  may  take 
place,  for  the  conditions  are  practically  tiic  same. 

•  Bliisiiis  :   Loc.  cit..  ii.  130. 


572  DISLOCATIONS. 

The  intervertebral  disk  seems  habitually  to  disappear  by  softening 
and  absorption  ;  and  the  ligaments  undergo  changes  similar  to  those 
observed  in  other  ligaments — that  is,  their  torn  portions  reunite  by 
cicatricial  tissue  or  they  contract  new  attachments  in  the  evolution 
of  the  process  of  repair,  and  they  may  even  become  ossified.  Tlie 
tendency  of  the  reparative  process  to  end  in  suppuration,  which  has 
been  observed  to  be  exceptionally  marked  after  fracture  of  the  verte- 
brae, has  been  manifested  also  after  dislocation,  although  possibly  only 
in  cases  complicated  by  fracture. 

Etiology.  The  causes  have  been  habitually  described  as  direct  and 
indirect  violence  and  muscular  action.  The  distinction  between  direct 
and  indirect  violence  is  made  by  classifying  under  the  latter  those  cases 
in  which  the  force  has  acted  upon  the  column  at  some  distance  from 
the  point  of  dislocation  to  bend  it  in  one  or  another  direction,  and 
under  the  former  those  in  which  the  force  has  acted  directly  upon  the 
dislocated  vertebra.  But  the  mechanism — in  most,  if  not  in  all  cases 
— is  certainly  the  same  ;  the  column  is  forcibly  bent,  and  the  dislocation 
is  produced  by  this  forcible  bending,  just  as  a  rod  may  be  bent  or  broken 
by  grasping  and  approximating  its  two  ends  with  or  without  the  aid  of 
direct  pressure  against  its  centre.  In,  the  cases  of  dislocation  by  mus- 
cular action  the  cervical  vertebrae  alone  have  been  involved,  and  the 
movement  has  been  that  of  exaggerated  rotation  or  dorsal  flexion. 

Symptoms  and  Diagnosis.  Most  of  the  symptoms  of  dislocation 
are  the  same  as  those  of  fracture  of  the  vertebrae.  There  is  usually  the 
same  history  of  violence  acting  upon  the  spinal  column,  either  directly 
or  indirectly,  to  bend  it  beyond  the  limit  of  its  normal  range  of  motion, 
localized  pain  increased  by  movement  or  manipulation,  inability  to 
stand,  partial  or  complete  paralysis  below  the  point  of  injury,  diminu- 
tion or  exaggeration  of  the  normal  mobility  of  the  affected  part,  with 
or  without  reflex  muscular  rigidity  of  the  upper  segment  of  the  column, 
and  deformity  recognizable  by  sight  or  touch.  The  symptoms  which 
are  thought  to  be  of  most  service  in  establishing  the  differential  diag- 
nosis between  these  two  injuries  are  crepitus  and  abnormal  mobility 
at  the  point  of  injury  in  fracture,  and  their  absence  in  dislocation. 
Unfortunately,  crepitus  is  not  always  obtainable  in  fracture  by  such 
manipulations  as  are  permissible,  and  it  may  be  present  in  dislocation 
accompanied  by  fracture — that  is,  in  a  condition  in  which  the  disloca- 
tion is  the  important  injury,  and  the  fracture  a  com])aratively  unim- 
portant addition.  Rigidity  of  the  column  at  the  injured  point  is 
common  but  not  constant  in  dislocation,  and  it  may  be  caused  in  frac- 
ture, or  even  in  contusion  or  sprain,  by  muscular  contraction.  But 
while  a  positive  differential  diagnosis  may  not  often  be  possible,  a  prob- 
able diagnosis  may  frequently  be  made,  at  least  when  the  injury  is  in 
the  cervical  region,  by  attention  to  the  attitude  and  rigidity  of  the 
neck,  by  recognition  of  the  change  in  the  relations  of  the  transverse 
processes,  or  of  the  bodies  of  the  vertebrae  so  far  as  they  are  accessible 
to  examination  in  the  pharynx,  or  of  the  lower  si>inous  processes,  and 
by  the  impossibility  of  correcting  the  displacement  by  pressure. 

On  the  other  hand,  muscular  contraction  and  pain  due  simply  to 


DISLOCATIONS  OF   THE   VERTEBRA.  573 

bruising  of  muscles  or  nerves  or  to  inflammation  of  the  vertebral  joints 
may  produce  an  attitude  and  rigidity  closely  resembling  those  of  dis- 
location. 

For  the  recognition  of  hsematomyelia — motor  paralysis,  thermo- 
ansesthesia,  and  analgesia  with  preservation  of  tactile  sensibility — see 
Chapter  XI. 

Deformity.  The  deformity  consists  in  displacement  of  the  spinous 
or  transverse  processes  forward  or  backward  or  to  one  side,  and  is  to  be 
I'ecognized  by  palpation.  The  displacement  of  the  transverse  processes 
can  be  recognized  by  touch  only  in  the  neck,  that  of  the  spinous  pro- 
cesses everywhere  except  in  the  upper  cervical  region  unless  the  patient 
is  very  fat.  The  body  of  the  displaced  vertebra  is  accessible  to  exami- 
nation only  in  the  pharynx  and  occasionally,  as  in  a  case  reported  by 
Dupuytren,  by  deep  pressure  through  the  anterior  abdominal  wall. 

Pain,  although  sometimes  absent,  is  commonly  present,  and  is  pro- 
voked or  increased  by  movements  of  the  body  or  by  direct  pressure 
upon  the  injured  region.  In  some  cases  it  is  referred  only  to  the  point 
of  injury,  in  others  it  is  radiated  along  the  course  and  over  the  region 
of  distribution  of  the  affected  nerves. 

Paralysis,  entirely  absent  in  some  cases,  may  be  partial  or  com- 
plete within  the  affected  region  ;  usually  the  two  sides  of  the  body  are 
similarly  affected  (paraplegia),  and  limitation  to  a  lateral  half  of  the 
body  (hemiplegia)  is  unknown  except  where  the  paralysis  has  been  only 
partial.  Motor  paralysis  is,  as  a  rule,  more  marked  and  extensive  than 
sensory  paralysis. 

Paralysis  has  been  observed  in  the  muscles  of  the  column  adjoining 
the  point  of  injury,  in  some  or  all  of  the  parts  of  the  body  below  the 
point  of  injury,  and  occasionally  in  those  lying  above  it.  The  last- 
mentioned  extension  is  to  be  explained  by  mechanical  injury  to  the 
cord  at  a  higher  point  than  the  dislocation,  as  by  overstretching  in 
diastasis,  or  by  extravasation  of  blood,  or  by  the  extension  of  inflam- 
matory processes  set  up  by  the  injury. 

Instead  of  paralysis,  or  in  association  with  it,  may  be  observed  mus- 
cular contractions,  neuralgic  pains,  and  hypersesthesia,  presumably  de- 
pendent upon  inflammatory  changes  in  the  cord  and  meninges.  In  a 
few  cases  there  have  been  general  convulsions,  promptly  followed  by 
death. 

In  addition  to  these  symptoms  of  injury  of  the  cerebro-spinal  nerves 
and  centres  are  others  of  widely  different  character  and  involving  many 
different  tissues  and  organs,  which,  as  Hutchinson  ^  has  pointed  out  in 
a  valuable  and  very  interesting  paper,  may  be  referred  to  changes  in 
the  sympathetic,  especially  the  vasomotor  system.  Thus,  sudden  rises 
of  temperature,  general  or  local  and  of  longer  or  shorter  duration,  may 
be  observed,  sometimes  associated  with  ])allor  of  the  surfjice  or  with 
marked  pulsation  in  the  arteries.  If  the  injury  is  in  the  cervical  region 
the  heart-beat  becomes  slow  but  does  not  also  show  the  intermissions 
that  commonly  accompany  the  slow  ])ulsc  of  injury  to  the  brain. 

^  Hutchinson  :  Lontlon  Hospital  Report,  1866,  vol.  iii.  p.  357. 


574  DISLOCATIONS. 

Immobility  of  one  or  both  pupils,  with  a  slight  degree  of  contrac- 
tion, has  been  noted  ;  in  other  cases  immobility  with  dilatation. 

Priapism  may  accompany  injury  of  the  lower  cervical  and  upper 
and  middle  dorsal  regions  when  it  is  sufficient  to  cause  paraplegia. 
Its  frequency,  compared  with  all  cases  in  males,  was  found  by  Blasius 
to  be  1  to  5  at  the  fourth  cervical,  1  to  3.6  at  the  fiftli,  1  to  2.7  at  the 
sixth,  and  1  to  2.5  at  the  seventh.  He  adds  that  it  was  present  in 
fourteen  out  of  twenty-five  cases  of  fracture  of  the  sixth  cervical  ver- 
tebra. The  condition  of  the  member  appears,  however,  not  always  to 
be  that  of  normal  physiological  erection,  but  rather  of  simple  engorge- 
ment, the  member  remaining  comparatively  flaccid  although  swollen. 
In  a  few  cases  the  priapism  has  been  provoked  only  by  the  additional 
application  of  a  local  irritant,  as  the  passage  of  a  catheter. 

The  rapid  formation  of  bed-sores  has  also  been  attributed  to  vaso- 
motor or  trophic  changes,  but  while  it  is  possible  that  such  changes 
may  act  as  a  predisposing  cause,  yet  the  immediate,  determining  cause 
appears  to  be  rather  the  prolonged,  unrelieved  pressure  to  which  the 
parts  are  subjected  in  consequence  of  the  paralysis. 

The  occurrence  of  cystitis  and  ammoniacal  decomposition  of  the 
urine  within  the  bladder  has  also  been  explained  in  the  same  manner, 
but  seems  rather  to  be  the  consequence  of  over-distention  of  the  bladder 
and  of  the  use  of  the  catheter.  The  later  consequences  of  this  cystitis 
are  extremely  serious  and  may  hasten  or  be  the  immediate  cause  of 
death. 

Injury  to  or  change  in  the  vasomotor  nerves  has  been  thought  to  be 
the  cause  also  of  changes  sometimes  observed  in  the  lungs.  In  two 
cases  elsewhere  mentioned  I  have  known  fracture  of  the  cervical  ver- 
tebrae to  be  followed  by  expectoration  of  blood  coming  from  the  lungs, 
and  Blasius  (following  Moritz)  describes  a  pulmonary  congestion  ap- 
pearing promptly,  marked  at  first  by  increased  secretion,  and  rapidly 
causing  death  by  oedema  of  the  lungs,  usually  on  the  second  or  third  day. 

Prognosis.  The  injury  is  commonly  deemed,  and  with  good  reason, 
one  that  places  the  life  of  the  patient  in  great  danger.  Of  the  278 
cases  he  collected  Blasius  collated  159  in  which  the  diagnosis  was  cer- 
tain;  of  these  36  recovered  and  123  died,  a  proportion  of  22.6  per 
cent,  of  recoveries,  or  1  in  4.4.  It  is  well  worthy  of  note,  also,  that 
of  these  36  recoveries  the  dislocation  was  completely  reduced  in  27 
and  partly  reduced  in  2,  and  that  all  these  29  and  5  of  the  remaining 
7  were  dislocations  of  the  cervical  vertebrae. 

In  the  fatal  cases  death  usually  followed  promptly  upon  the  receipt 
of  the  injury.  Of  113  authentic  cases  more  than  half  died  within  the 
first  week,  the  others  at  varying  periods  up  to  five  months.  Death, 
especially  in  the  cases  in  which  it  occurs  promptly,  is  usually  the  con- 
sequence of  the  injury  to  the  cord  or  of  the  inflammatory  processes 
set  up  in  it  by  the  injury  ;  but  even  when  such  injury  exists,  especially 
if  situated  in  the  lower  portion  of  the  cord,  life  may  be  indefinitely  pro- 
longed. Simple  compression  of  the  cord  involves  less  danger  to  life 
than  its  complete  or  partial  division  or  crushing,  and  relief  of  the  com- 
pression may  be  followed  by  restoration  of  function.     If  the  compres- 


DISLOCATIONS  OF   THE   VERTEBRA.  575 

sion  takes  place  gradually,  even  to  a  very  marked  degree  and  at  the 
upper  end  of  the  cord,  as  in  several  reported  cases  of  cervical  spinal 
caries,  prolongation  of  life  is  still  possible,  and  even  marked  and  per- 
manent compression  at  the  level  of  the  atlas  and  axis  has  in  two  reported 
cases  not  proved  immediately  fatal.  In  one  ^  of  these,  dislocation  of 
the  atlas  forward  from  both  the  occiput  and  the  axis  with  fracture  of 
the  odontoid  process,  the  canal  was  reduced  to  a  triangidar  slit  two 
millimetres  wide  on  one  side  and  five  on  the  other  ;  the  patient  survived 
five  months,  being  completely  paralyzed  during  most  of  the  time.  In 
the  other  case,^  incomplete  dislocation  of  the  occiput  from  the  atlas 
due  to  caries,  the  patient  survived  three  months  and  died  of  tubercle 
of  the  brain. 

If  the  dislocation  is  reduced  the  symptoms  may  disappear  promptly, 
or  the  paralysis  may  persist  in  whole  or  in  part,  and  the  case  may  even 
terminate  fatally  in  consequence  of  the  injury  done  to  the  cord  or  its 
envelopes. 

Treatment.  This  must  be  directed  to  the  reduction  of  the  disloca- 
tion, the  prevention  of  its  recurrence,  and,  if  reduction  is  im})ossible,  to 
the  relief  of  the  consequences  of  the  displacement.  If  reduction  is 
to  be  attempted  it  should  be  done  promptly,  and  yet  it  must  be  added 
that  it  has  been  successfully  made  in  several  cases  as  late  as  the  eighth 
or  ninth  day  after  the  accident,  and  in  one  after  the  lapse  of  two 
months,  and  was  followed  by  the  prompt  or  gradual  disappearance  of 
the  paralysis. 

The  attempt  to  discriminate,  with  reference  to  the  question  of  attempt- 
ing reduction,  between  cases  in  which  the  paralysis  is  due  to  simple 
compression  of  the  cord  and  those  in  which  it  is  due  to  its  laceration 
or  the  effusion  of  blood  within  the  canal  is  impracticable,  because  of 
the  impossibility  of  making  a  positive  differential  diagnosis  between 
those  conditions.     For  the  diagnosis  of  hsematomyelia  see  Chapter  XL 

The  possibility  that  the  attempt  may  cause  the  instant  death  of  the 
patient,  especially  when  the  dislocation  is  in  the  upper  part  of  the  cer- 
vical spine,  is  a  weighty  factor  in  the  problem,  but  should  not,  in  my 
judgment,  deter  the  surgeon  if  the  patient  or  his  friends  accept  the  risk. 
It  should  only  stimulate  him  to  make  the  most  accurate  possible  diag- 
nosis as  regards  the  seat,  direction,  and  mode  of  production  of  the 
dislocation,  and  most  cautiously  to  select  and  execute  the  necessary 
manoeuvres.  The  urgency  of  the  symptoms  may  leave  him  but  scant 
time  for  observation  and  reflection,  and  the  history  of  the  case  may 
throw  no  light  upon  the  mode  of  production,  so  that  the  general  rule 
to  return  the  dislocated  part  along  the  path  by  which  it  escaped  from 
its  position  cannot  be  knowingly  and  deliberately  followed.  Under 
such  circumstances  the  surgeon  must  trust  to  traction  aided  by  such 
flexion  and  rotation  of  the  column  as  his  best  scrutiny  of  the  displace- 
ment and  knowledge  of  the  relations  of  the  articular  processes  may 
suggest.     Anaesthesia  should  usually  be  employed. 

The  return  of  the  bone  to  its  place  is  usually  indicated  by  a  distinct 

^  Costes:  Schmidt's  Jahrbiich.,  vol.  Ixxix.  p.  208. 

2  Daniste  :  Bull,  de  la  Soc.  Anatomique,  1838,  vol.  xiii.  p.  144. 


576  DISLOCATIONS. 

sound,  and  the  rigidity  which  is  usually  present  gives  place  to  normal 
mobility. 

If  the  dislocation  is  comparatively  slight,  moderate  lateral  pressure 
may  effect  reduction,  as  in  a  remarkable  case  reported  to  Blasius^  by 
Richter.  A  lad,  eleven  or  twelve  years  old,  consulted  Richter  because 
of  deformity  and  stiffness  of  the  neck  caused  by  a  fall.  He  found  the 
spinous  process  of  the  third  cervical  vertebra  slightly  displaced  to  one 
side,  and  that  pressure  upon  it  caused  pain.  No  paralysis.  An  attempt 
to  reduce  the  dislocation  by  traction  on  the  head  failed,  and  the  child 
was  sent  home  to  await  another  attempt.  On  the  way,  the  child,  who 
had  heard  and  comprehended  the  diagnosis,  stopped  by  a  wall,  leaned 
his  head  and  shoulder  against  it,  and  pressed  forcibly  with  the  thumb 
against  the  opposite,  convex  side  of  the  neck,  and  instantly  reduced 
the  dislocation.  The  story  was  confirmed  by  the  child's  companions, 
and  the  surgeon  at  his  visit  found  the  neck  straight,  normally  movable, 
and  free  from  pain. 

After  reduction  has  been  made  no  other  retentive  measures  than  rest 
in  bed  are  ordinarily  required,  but  if  there  is  reason  to  fear  recurrence 
the  parts  may  be  immobilized  by  gypsum  bandages  or  padded  wire 
splints  that  embrace  the  entire  trunk  if  the  injury  is  situated  below 
the  shoulders,  and  the  head  and  chest  if  it  is  in  the  cervical  region. 

If  reduction  cannot  be  made  immobilization  is  still  necessary  to 
favor  the  formation  of  firm  adhesions  and  the  solidification  of  the 
bones  in  their  new  relations ;  and  in  addition  measures  may  be  needed 
to  meet  the  indications  of  other  symptoms.  Of  the  latter  the  most 
urgent  is  the  acute  hypersemia  of  the  lungs  that  has  occasionally  been 
observed,  and  this  is  most  promptly  and  satisfactorily  met  by  free 
venesection.  The  need  of  regular  catheterization  in  the  paralytic  cases 
must  not  be  overlooked.  Permanent  drainage  of  the  bladder  through 
a  perineal  incision  has  been  employed,  apparently  with  advantage,  in 
some  cases.  Suprapubic  drainage  would  probably  be  preferable  on  the 
score  of  cleanliness  and  easy  attention. 

DISLOCATIONS    OF    THE    OCCIPUT    AND  CERVICAL   VERTEBRA. 

Dislocations  are  far  more  frequent  in  this  region  than  in  the  others. 
The  fifth  cervical  vertebra  is  the  one  most  frequently  dislocated.  The 
anatomical  differences  between  the  articulations  of  the  atlas  with  the 
occiput  and  axis  and  those  of  the  other  vertebrse  are  such  that  a  sepa- 
rate description  of  the  injury  at  the  upper  end  of  this  region  is  necessary. 

1.  Dislocations  of  the  Occiput  (from  the  Atlas). 

The  articulations  between  the  atlas  and  the  condyles  of  the  occip- 
ital bone  are  formed  on  each  side  by  a  long,  oval  articular  surface  on 
the  atlas,  which  is  concave  both  from  before  backward  and  from  side 
to  side ;  the  long  axis  of  each  runs  from  in  front  outward  and  back- 
ward and  the  outer  margin  of  each  is  higher  than  the  inner  margin,  so 
that  each  articular  surface  looks  upward,  inward,  and  backward,  and 

^  Blasius :  Loc.  cit.,  vol.  civ.  p.  114. 


DISLOCATIONS  OF  THE  ATLAS.  577 

together  they  constitute  a  cuji-shaped  socket  into  which  the  rounded 
condyles  of  the  occipital  bone  fit,  and  upon  which  they  have  a  motion 
only  of  flexion  and  extension.  In  addition  to  the  ligaments  uniting 
the  two  bones  there  are  other  and  strong  ones  within  the  canal  which 
directly  unite  the  posterior  surface  and  apex  of  the  odontoid  process 
with  the  occipital  bone  and  thus  aid  in  opposing  the  separation  of  the 
atlas  from  the  latter. 

The  dislocation  was  formerly  deemed  quite  a  common  one,  and  to 
this  opinion  succeeded  another  more  in  harmony  with  the  anatomical 
conditions  of  the  joint  but  still  erroneous,  namely,  that  it  had  never 
occurred.  There  are,  however,  three  observations  which  positively 
demonstrate  the  occurrence  of  the  injury,  those  of  Costes,'  Bouisson,^ 
and  Milner.^  In  the  former  a  lad  fifteen  years  old  was  thrown  down 
and  beaten  upon  the  back  of  the  neck,  by  which  the  atlas  was  displaced 
forward  from  its  articulations  with  both  the  occipital  bone  and  the 
axis,  and  the  odontoid  process  of  the  latter  was  broken  off.  The 
patient's  head  remained  inclined  forward,  and  movements  of  the  neck 
were  difticult.  A  few  days  later  hypersesthesia  and  pai'alysis  of  motion 
appeared,  and  persisted,  without  treatment,  for  four  months ;  then  the 
right  arm  and  leg  became  painful,  and  he  was  taken  to  the  hospitak 
The  pulse  was  feeble  and  slightly  quickened  ;  at  the  posterior  part  of 
the  neck  was  a  firm  swelling  projecting  a  little  on  the  right  side  which 
subsequently  proved  to  be  the  ])osterior  part  of  the  axis,  and  the  chin 
was  turned  to  the  left  and  so  depressed  as  almost  to  touch  the  chest. 
He  died  thirty-six  days  after  admission  to  the  hospital. 

At  the  autopsy  the  skull  was  found  dislocated  backward  from  the 
atlas,  the  articular  surfaces  being  compUstely  separated  on  the  right 
side,  while  on  the  left  the  anterior  and  inner  part  of  the  articular  sur- 
face of  the  condyle  was  still  in  contact  with  the  posterior  part  of  that 
of  the  atlas.  At  the  same  time  the  atlas  was  tilted  forward,  rotated 
to  the  left  in  front  and  to  the  right  behind,  and  displaced  forward  upon 
the  axis;  the  odontoid  process  was  broken  off  at  the  base  and  reunited 
by  fibrous  tissue  in  an  almost  horizontal  position  with  the  body  of  the 
axis.  The  posterior  arch  of  the  atlas  was  so  closely  approximated  to 
the  body  of  the  axis  that  the  interval  between  them  Avas  reduced  to  a 
triangular  slit  five  mm.  wide  on  the  left  side  and  two  mm.  on  the  riglit. 

In  the  second  and  third  cases  the  patients  were  instantly  killed. 

A  unique  case  of  unilateral  dislocation  forward,  presumably  by 
forcible  rotation,  was  reported  by  Jonas*  who  first  saw  it  a  year  after 
its  occurrence.  It  was  caused  in  an  adult  by  forcible  mani])ulati()ns 
made  by  an  osteopath  to  cure  rheumatism.  The  head  was  fixed  in 
full  flexion,  the  chin  resting  on  the  chest.  Dr.  Jonas  exposed  the  region 
by  a  posterior  incision  and  found  the  left  occipital  condyle  displaced 

1  Costes:  Schmidt's  Jahrbiich,  vol.  Ixxix,  p.  208,  and  Malgaigne:  Des  Luxations,  p.  ;^29. 
Both  these  accounts  are  abstracts  of  the  orisinai  report  in  the  .Journal  de  Bordeaux, 
August,  1852,  and  they  differ  materially  from  each  other  m  some  ponits.  In  the  account 
here  given  I  have  in  the  main  followed  the  former,  since  Malgaigne's  appears  lo  ha\c 
been  taken  from  an  abstract,  not  from  the  original  paper. 

2  Bouisson:  Schmidt's  Jahrbuch,  vol.  Ixxxii,  p.  216,  from  Revue  M6d.  C'lururg.  de 
Paris,  vol.  ii,  p.  35.5. 

3  Milner:  St.  Bartholomew's  Hospital  Reports,  vol.  x,  p.  314. 
"  Jonas:  Surg.,  Gyn.  and  Obst.,  July',  1916,  p.  48. 


578  DISLOCATIONS. 

forward  from  the  articular  process  of  the  atlas.  He  excised  the  "arch 
of  the  atlas  with  the  left  superior  articular  surface,"  and  then,  the 
head  not  yet  being  freed,  he  cut  away  with  a  rongeur  part  of  the  right 
articulation. 

The  rarity  of  the  occurrence  is  readily  explained  by  the  extent  of 
the  articular  surfaces,  the  strength  of  the  ligaments,  and  the  extra- 
articular checks  to  the  movement  of  the  skull  upon  the  atlas,  the  effect 
of  which  is  to  cause  exaggerated  movements  of  lateral  or  antero- 
posterior flexion  of  the  head  to  be  transmitted  to  the  lower  vertebrae. 

Treatment.  If  treatment  is  called  for,  the  attempt  to  reduce  should 
be  made  by  steady  traction  on  the  head  combined  with  such  coaptative 
pressure  upon  it  and  the  vertebrae  as  would  be  suggested  by  the  char- 
acter of  the  displacement. 

2.  Dislocations  of  the  Atlas  (from  the  Axis). 

The  articulation  between  the  atlas  and  axis  is  composed  not  only  of 
the  two  lateral  articulations  as  in  the  other  vertebrae,  but  also  of  that 
between  the  odontoid  process  and  the  anterior  arch  of  the  atlas.  This 
process,  which,  genetically,  is  the  separated  body  of  the  atlas  that  has 
united  with  the  axis,  is  placed  vertically  behind  the  anterior  arch  of 
the  atlas,  and  is  firmly  held  in  place  by  the  strong  transverse  ligament 
of  the  atlas,  by  the  two  alar  or  check  ligaments  which  pass  from  the 
base  of  the  process  to  the  occipital  bone  at  the  margin  of  the  foramen 
magnum,  and  by  the  vertical  band  of  the  transverse  ligament,  the 
suspensory  ligament,  and  the  posterior  occipito-axial  ligament  which 
overlies  the  others. 

Dislocation  forward  or  backward  is  possible  only  after  fracture  of  the 
odontoid  process  or  rupture  of  the  transverse  ligament,  or  by  the  slip- 
ping of  the  process  beneath  the  ligament.  The  number  of  cases  of  the 
injury  demonstrated  by  autopsy  is  fairly  large  and  contains  examples 
of  all  three  forms.  In  most  of  the  reported  cases  the  injury  was  a 
diastasis  or  incomplete  separation  of  the  articular  surfaces,  the  atlas 
being  displaced  forward,  and  usually  so  inclined  that  its  anterior  arch 
lay  in  front  of  the  body  of  the  axis.  If,  in  this  change  of  place,  the 
odontoid  process  is  broken  off  and  accompanies  the  atlas,  the  proba- 
bility of  dangerous  compression  of  the  cord  is  somewhat  lessened. 
The  other  forms  that  have  been  demonstrated  are  dislocations  forward 
and  backward  of  both  articular  surfaces ;  dislocation  forward  on  one 
side  only  (unilateral  dislocation  forward)  has  been  observed  only  clin- 
ically except  in  one  case  ^  in  which  there  was  also  a  similar  dislocation 
of  the  sixth  cervical.  There  is  some  reason  to  think  that  some  of  the 
obscure  reported  cases  that  ended  in  recovery  may  have  been  of  the 
kind  designated  as  "  bilateral  dislocation  in  opposite  directions,"  that 
in  which  one  articular  surface  is  displaced  forward  and  the  opposite 
one  backward,  for  experiment  shows  that  this  displacement  can  exist 
without  causing  compression  of  the  medulla.  A  case  observed  by 
Sedillot  probably  was  of  this  kind.     (Mde  infra.) 

The  following  are  examples  of  the  rarer  forms: 

1  Franchomme;  Journ.  des  Sci.  Med.  de  Lille,  May  29,  1891. 


DISLOCATIONS  OF   THE  ATLAS.  579 

Dislocation  Forward  without  RrPTURE  of  the  Transverse 
Ligament.  A  man^  sixty  years  old  fell  from  a  height  of  four  or  five 
metres,  striking  upon  his  head,  and  survived  ten  hours.  The  head 
was  held  in  moderate  dorsal  flexion,  but  was  freely  movable.  The 
odontoid  process  had  passed  under  the  transverse  ligament,  and  com- 
pressed the  medulla.  The  right  alar  ligament  was  torn,  the  left 
untorn.  The  articular  surfaces  of  the  atlas  had  moved  forward  upon, 
but  had  not  entirely  left,  those  of  the  axis.    There  was  no  fracture. 

A  similar  case  is  reported  by  Orton,-  in  which  all  the  ligaments 
uniting  the  axis  to  the  atlas  and  occipital  bone  were  torn,  but  the 
transverse  ligament  was  uninjured,  and  the  odontoid  process  lay  behind 
it  compressing  the  cord.  The  injury  was  caused  by  a  blow  of  the  fist 
received  obliquely  from  beliind,  on  the  angle  of  the  jaw.  Death  was 
instantaneous.  These  two  are  the  only  positive  examples  of  this 
injury. 

Dislocation  Backward.  A  woman 3  sixty-eight  years  of  age  fell 
while  descending  a  ladder,  struck  upon  her  forehead,  and  died  instantly. 
The  atlas  was  dislocated  backward  on  both  sides,  the  anterior  ligament 
detached,  the  capsular  ligaments  in  front  torn,  the  odontoid  process 
broken  at  its  base,  and  the  posterior  arch  of  the  atlas  broken  on  each 
side  near  the  transverse  process.  The  fracture  of  the  atlas  was  thought 
to  have  been  caused  by  its  impact  against  the  spinous  process  of  the 
axis. 

There  is  no  other  reported  case  in  which  this  variety  has  been 
demonstrated  post  mortem,  but  Malgaigne  quotes  from  Ehrlich  a  sup- 
posed case  which  ended  in  recovery. 

Bilateral  Dislocation  in  Opposite  Directions.  Sedillot^  re- 
ported the  case  of  a  girl  who  had  suffered  for  some  time  with  stiffness 
of  the  neck  and  deviation  of  the  head  to  the  left,  although  it  could  be 
turned  to  the  right.  The  injury  had  been  caused  by  a  man  who  seized 
her  by  the  head  from  behind  and  forcibly  twisted  it  to  the  side  toward 
which  it  remained  deviated.  She  died  seven  weeks  later,  with  increas- 
ing paralysis.  The  autopsy  revealed  a  "  dislocation  of  the  atlas,"  the 
details  of  which  are  not  given.  The  front  of  the  odontoid  process  was 
rough,  and  the  odontoid  ligaments  were  torn  and  partly  destroyed,  but 
there  Avas  no  pus.  Only  the  anterior  portion  of  tlie  cord  was  softened. 
Blasius  describes  this  case  as  one  of  bilateral  dislocation  in  opposite 
directions;  although  it  was  probably  such,  the  description  does  not 
prove  it. 

In  the  commoner  forms  of  diastasis  with  inclination  and  displace- 
ment of  the  atlas  forward,  and  in  complete  forward  dislocation  the 
transverse  ligament  is  ruptured,  or  the  odontoid  process  is  broken  off 
and  accompanies  the  atlas.  In  diastasis  all  the  ligaments  uniting  the 
atlas  to  the  axis  are  ruptured  ;  in  dislocation  forward  the  ligaments  of 
the  posterior  arch  are  sometimes  untorn.  In  a  case  reported  by  Philips.s 
the  posterior  arch  of  the  atlas  was  broken  off  on  each  side  and  remained 

'  Journal  de  ChirurKie  dc  MalKaignc,  1844,  p.  370. 

2  0rton:  Laiifet,    1S76,   i,   p.  S53. 

■■'  Melfhiori.  quoted  I>.\-  Alalirnitrno,  loo.  fit.,  p.  .333. 

*  Sedillot:  Gazette  Medicalc,  1.S42,  p.  77(1. 

*  Philips:  Med.-ChirurK.  Trans.,  vol.  xx,  p.  78. 


580  DISLOCATIONS. 

in  place,  while  the  anterior  portion,  including  the  articular  surfaces  and 
carrying  with  it  the  fractured  odontoid  process,  was  displaced  so-  far 
forward  and  downward  that  it  lay  entirely  in  front  of,  and  became 
united  to,  the  body  of  the  axis.  The  patient  survived  forty-seven 
weeks  and  died  of  hydrothorax.  The  injury  gave  rise  to  no  marked 
symptoms  except  persistent  stiffness  and  pain  in  the  neck,  which  were 
attributed  during  life  to  a  strumous  arthritis  set  up  by  the  injury. 
I  have  met  with  no  mention  of  injury  to  the  vertebral  arteries  or  veins. 
The  spinal  cord  may  be  torn  across  in  part  or  entirely,  or  crushed, 
or  simply  compressed.  In  double  dislocation  forward,  it  is  most  likely 
to  escape  injury  if  the  odontoid  process  is  broken  off.  On  theoretical 
grounds,  it  is  also  thought  not  to  be  greatly  endangered  in  bilateral 
dislocation  in   opposite   directions. 

Cause.  The  cause  has  usually  been  a  fall  or  blow  upon  the  head. 
In  forward  dislocation,  and  in  complete  diastasis,  the  force  has  prob- 
ably always  been  so  exerted  as  to  bend  the  head  toward  the  breast ;  in 
partial  diastasis,  with  rupture  of  the  ligaments  of  only  one  side,  the 
inclination  must  have  been  toward  the  opposite  side. 

Unilateral  dislocation  or  bilateral  dislocation  in  opposite  directions  may 
be  produced  by  exaggerated  rotation  of  the  .head,  as  in  Sedillot's  case. 
Symptoms.  In  simple  diastasis  without  displacement,  and  without 
injury  of  the  cord,  there  may  be  no  symptoms  except  pain  and  exag- 
gerated mobility  of  the  head,  and  even  the  latter  may  be  lacking  because 
of  spasmodic  contraction  of  the  muscles.  In  the  common  form,  dislo- 
cation forward,  the  chin  is  depressed  upon  the  chest,  and  a  prominence 
may  be  felt  at  the  back  of  the  neck,  below  the  occiput,  formed  by  the 
spinous  process  of  the  axis.  In  the  pharynx  may  be  felt  the  project- 
ing anterior  arch  of  the  atlas.  Pain  is  always  present,  and  usually 
severe.  Philips's  case,  above  quoted,  is  a  marked  exception  in  respect 
of  pain,  disability,  and  deformity.  The  nervous  symptoms  vary  with 
the  degree  of  injury  to  the  cord. 

Prognosis.  The  prognosis,  even  accepting  the  cases  of  doubtful  diag- 
nosis followed  by  recovery,  is  very  bad.  Death  may  be  caused  imme- 
diately, or  suddenly  at  a  later  period  by  tiie  shifting  of  the  loosened 
bones  and  the  consequent  compression  of  the  cord,  or  by  the  progress 
of  the  changes  induced  by  the  primary  traumatism. 

Treatment.  Immediate  reduction  of  the  displacement  and  the  pre- 
vention of  its  recurrence  are  imperative,  if  the  former  can  be  accom- 
plished without  such  violence  as  would  in  itself  endanger  the  life  of 
the  patient.  Although  Philips's  case  furnishes  proof  that  the  persist- 
ence of  the  displacement  is  not  necessarily  incompatible  with  the  pro- 
longation of  life  and  activity,  and  although  this  proof  is  supported  by 
the  survival  in  fair  condition  of  several  other  patients  who  have 
received  injuries  at  the  upper  part  of  the  cervical  spine,  the  exact 
nature  of  which  was  in  doubt,  but  which  were  followed  by  permanent 
rigidity  and  deformity  of  the  part,  yet  there  can  be  no  question,  I 
think,  of  the  propriety  of  making  or  even  of  the  obligation  to  make, 
cautious,  well-considered  attempts  to  correct  the  displacement.  Even 
if  dangerous  pressure  upon  the  cord  has  not  at  the  time  taken  place, 
yet  it  is  certain  tliat  the  condition  is  full  of  the  gravest  risk.     The 


DISLOCATIONS  OF   THE  CERVICAL   VERTEBRA.  581 

displacement  may  gradually  increase,  as  in  Dubreuil's  case,  in  which 
the  chin  did  not  touch  the  chest  until  the  tenth  or  eleventh  day,  and 
death  occurred  suddenly  on  the  seventeenth,  or  the  fatal  increment  of 
displacement  may  be  suddenly  added  by  the  relaxation  of  the  spas- 
modically contracted  muscles,  or  by  an  incautious  movement  of  the 
patient,  or  even  of  his  attendants.  This  latter  has  occurred  even  after 
complete  reduction,  as  in  the  following  case,  which  I  quote  in  some  detail 
because  it  will  illustrate  many  of  the  prominent  features  of  the  injury. 

A  man^  fifty-eight  years  of  age  fell  down  a  hill-side  and  remained 
all  night  upon  the  ground  unconscious.  In  the  morning  he  tried  to 
walk  and  found  himself  "unsteady."  Help  came,  and  he  was  taken 
home.  When  seen  by  the  reporter  he  was  seated  in  a  chair,  his  chin 
resting  on  his  sternum,  his  head  and  neck  rigidly  fixed.  He  was  con- 
scious, not  paralyzed,  and  complained  of  great  pain  in  the  neck.  There 
was  a  marked  prominence  at  the  back  of  the  neck  below  the  occijnit. 

By  steady  traction  upon  the  sides  of  the  head  the  displacement  was 
completely  reduced  with  a  distinct  snap  and  crepitus,  and  the  pain  was 
relieved.  A  week  later  he  sat  up  in  bed,  and  immediately  fell  back 
dead,  with  reproduction  of  the  original  deformity. 

The  autopsy  showed  that  the  odontoid  process  had  been  broken  off 
with  a  portion  of  the  body  of  the  axis,  and  displaced  forward  with  the 
atlas  (the  transverse  ligament  remaining  intact)  so  far  that  the  lateral 
articular  surfaces  w^ere  almost  entirely  separated. 

As  it  seems  probable  from  the  shape  of  the  bones  that  dislocation 
forward,  except  in  cases  that  are  immediately  fatal,  is  very  rarely 
complete,  the  traction  upon  the  head  should  be  directed  somewhat 
backward,  as  well  as  upward,  so  as  to  avoid  increase  of  the  displace- 
ment, and  may  be  combined  with  counter-pressure  against  the  back  of 
the  neck. 

After  reduction  has  been  effected,  and  in  cases  of  diastasis  without 
displacement,  the  head  and  neck  must  be  made  immovable  by  suitable 
dressings. 

3.  Dislocations  of  the  Lower  Six  Cervical  Vertebrae. 

These  are  by  far  the  most  common  of  the  dislocations  of  the  spine, 
and  the  articulations  between  the  fourth  and  fifth  and  between  the  fifth 
and  sixth  are  those  most  frequently  affected.  The  varieties  that  have 
been  observed  and  verified  are  diastasis,  bilateral  dislocation  forward, 
backward,  and  in  opposite  directions,  and  unilateral  forward.  Of  these 
the  bilateral  forward  and  backward  may  be  classed  as  dislocations  by 
flexion,  and  the  bilateral  in  opposite  directions  and  the  unilateral  for- 
ward as  dislocations  by  abduction  and  rotation.  The  bilateral  forward 
and  the  unilateral  forward  are  the  most  common.  The  statistics  of 
Blasius  show  that  of  108  cases  in  which  the  exact  nature  of  the  injury 
was  ascertained  23  were  diastases,  41  bilateral  dislocations  forward,  37 
unilateral  forward,  4  bilateral  in  opposite  directions,  and  3  hilatciMl 
backward;  to  the  latter  may  perhaps  be  added  8  others  in  which  the 
diagnosis  was  not  entirely  beyond  question. 

1  Gibbou;  Lancet,  18S5,  ii,  p.  429. 


582  DISLOCATIONS. 

The  positively  demonstrated  cases  of  bilateral  dislocation 
'backward  are  two  reported  by  Porta  and  one  by  Stanley.  The  latter 
of  the  fifth  cervical,  in  which  the  upper  five  vertel^rge  were  firmly  united 
to  one  another  by  bony  fusion,  has  been  quoted  above,  p.  568.  The 
dislocation  was  complete,  the  body  of  the  fifth  vertebra  resting  upon 
the  laminffi  and  spinous  process  of  the  sixth.  The  injury  was  caused 
by  a  fall  backward  upon  the  head  and  back.  Theoretically,  it  may  be 
assumed  that  hyperflexion  forward  of  a  vertebra,  combined  with  direct 
pressure  backward  upon  it,  would  produce  this  form  of  dislocation,  for 
by  the  flexion  a  diastasis  would  be  effected  in  which  the  posterior  and 
capsular  ligaments  would  be  torn,  and  then  the  direct  pressure  back- 
ward would  rupture  the  intervertebral  disk  and  produce  the  displace- 
ment. That  the  injury  is  rare  notwithstanding  the  frequency  of  the 
occasions  in  which  the  head  is  bent  forcibly  forward  is  to  be  explained 
by  the  normal  freedom  of  motion  in  this  direction  which  allows  the 
chin  to  be  depressed  upon  the  breast. 

Of  the  four  cases  of  bilateral  dislocation  in  opposite  direc- 
tions I  have  been  able  to  examine  the  original  reports  in  none.  Possibly 
the  one  attributed  to  Malgaigne  ^  is  the  same  as  the  case  described  in 
his  Luxations,  p.  371,  as  unilateral  forward  ;  if  so,  and  if  it  is  retained 
in  the  list,  it  w^ould  seem  proper  also  to  add  Martelliere's  case  mentioned 
by  Malgaigne  upon  the  following  page,  372,  as  resembling  his  own  in 
the  associated  slight  displacement  backward  of  the  opposite  inferior 
articular  process  with  rupture  of  the  capsule.  In  Malgaigne's  case 
there  was  also  chipping  of  the  lower  border  of  the  articular  surface  of 
the  dislocated  vertebra  on  the  side  of  the  principal  dislocation  with  the 
production  of  a  notch  in  which  the  upper  edge  of  the  underlying  pro- 
cess was  engaged.  Similar  chipping  of  the  same  border  w'as  found  in 
Martelliere's  case,  but  the  articular  process  had  passed  completely 
beyond  the  underlying  one  and  had  descended  in  front  of  it  to  a  dis- 
tance of  nearly  one-quarter  of  an  inch.  This  form  is  an  exaggeration 
of  the  unilateral  dislocation  forward,  and  their  causes  and  mode  of 
production  will,  therefore,  be  considered  together. 

In  bilateral  dislocation  forward  both  inferior  articular  sur- 
faces of  the  dislocated  vertebra  are  carried  forward  beyond  the  anterior 
borders  of  the  underlying  ones,  and  the  fixation  is  effected  either  by 
the  dropping  of  the  processes  into  the  notches  in  front  of  the  latter,  or, 
if  the  movement  forward  is  combined  with  anterior  flexion,  by  the 
interlocking  of  the  body  of  the  upper  vertebra  with  the  projecting 
lateral  borders  of  the  upper  surface  of  the  one  beneath.  Blasius  claims 
that  this  is  effected  almost  as  frequently  by  posterior  as  by  anterior 
flexion,  an  opinion  which  it  is  not  easy  to  accept. 

In  hyperflexion  forward  the  fulcrum  is  found  at  the  anterior  border 
of  the  body  of  the  vertebra,  and  the  first  effect  is  to  produce  diastasis 
with  rupture  of  the  posterior  and  capsular  ligaments,  and  then  as  the 
projecting  lip  on  the  inferior  anterior  border  of  the  body  of  the  upper 
vertebra  engages  in  front  of  the  upper  border  of  the  lower  one,  and 
the  force  continues  to  act,  not  simply  to  flex  but  also  to  crowd  the  head 

1  Malgaigne:  Revue  Med.  Chirurs-.  I<!l53. 


DISLOCATIONS  OF   THE  CERVICAL   VERTEBRA. 


583 


directly  down  toward  the  chest,  the  body  of  the  upper  vertebra  shps 
downward  and  forward,  by  which  movement  the  articular  surfaces  are 
separated  antero-posteriorly.  Then  if  the  neck  is  straightened  the 
body  of  the  vertebra  may  be  raised  to  its  original  level,  and  yet  the 
dislocation  will  be  maintained  by  interlocking  of  the  articular  pro- 
cesses. Under  such  circumstances  there  would  be  no  angle  in  the 
direction  of  the  neck,  but  only  a  depression  in  the  nape  and  projec- 
tion in  the  pharynx  corresponding  to  the  body  of  the  dislocated  vertebra. 
Occasionally  the  spinous  process  with  more  or  less  of  the  adjoining 
laminae  is  broken  off.  The  intervertebral  disk  is  always  torn,  and  so 
are  usually  the  ligamenta  flava  and  the  interspinous  ligament;  the 
longitudinal  (anterior  and  posterior)  ligaments  are  less  frequently  torn, 
often  only  stripped  off.  The  spinal  cord  may  be  compressed  or  crushed 
or  stretched,  or  may  escape  injury. 


Fig.  374. 


Fig.  375. 


Dislocation  of  the  neclc  by  flexion;  median 
section. 


^Bilateral  dislocation  by  flexion;  fourth  cervical 
vertebra;  from  behind.     (M.^lgaigne.) 


As  the  articular  surfaces  are  in  some  cases  almost  horizontal,  it  is 
conceivable  that  the  dislocation  may  be  produced  by  direct  \i()l('nce 
acting  upon  the  bone  from  behind  forward,  without  aid  of  cither 
ventral  or  dorsal  flexion  of  the  column. 

In  UNILATERAL  DISLOCATION  FORWARD^  (dislocation  by  abduction 
and  rotation)  the  articular  surface  on  one  side  of  the  upper  vertebra  is 
carried  upward  and  forward  until  its  posterior  edge  has  ])assed  the 
anterior  edge  of  the  one  with  which  it  articulates.  At  the  same  time 
the  spinous  process  moves  from  the  median  line  toward  tlu>  si(l(>  of  tlic 

'  Blasius  (loo.  eit.,  vol.  civ,  p.  .S2)  found  oiil\'  one  ease  of  unilateral  dislocation  back-ward 
— of  the  sixth  cervical — and  even  in  it  there  was  also  fracture  of  the  lamina  and  body 
of  the  seventh  vertebra  on  the  side  of  the  dislocation. 

41 


584 


DISLOCATIONS. 


Fig.  376. 


dislocation,  and  the  anterior  surface  of  the  body  projects  slightly  in 
front  of  that  of  the  underlying  one.  In  short,  the  movement  is  one  of 
rotation  and  abduction  about  the  opposite  articular  surface  as  a  centre, 
and  by  it  the  vertebral  canal  is  but  slightly  narrowed,  and  but  little  or 
no  violence  is  done  to  the  cord.  The  segment  of  the  column  above  the 
dislocation  is  abducted,  and  forms  with  the  lower  part  an  angle  or  curve, 
the  convexity  of  which  is  on  the  dislocated  side. 

The  normal  motion  in  the  articulations  of  this  region  is  one  of  rota- 
tion and  abduction.  The  dislocation  is  produced  by  carrying  the  move- 
ment beyond  its  normal  limits,  by  any 
force  which  over-abducts  or  over-rotates 
the  upper  part  of  the  column.  This 
force  may  be  an  external  one,  or  one 
developed  by  the  muscles  attached  to 
the  head.  Of  these  dislocations  by 
muscular  action  Volker^  collected  fovir- 
teen  more  or  less  certain  cases,  and  made 
them  the  basis  of  a  careful  study  of  the 
subject.  Additional  cases  have  since 
been  reported.  The  movement  which 
produces  the  lesions  is  a  sudden  turn  of 
the  head  to  one  side;  if  it  is  violent,  ill 
regulated,  if  its  momentum  is  unchecked 
by  the  antagonistic  muscles,  it  carries 
the  head  beyond  its  normal  limit,  and 
produces  the  dislocation  in  exactly  the 

Fig.  377. 


Bilateral  dislocation  backward,  cer- 
vical vertebra.  (U.  S.  Army  Med. 
Museum.) 


Complete  unilateral  dislocation  by  rotation  or  abduction. 


same  manner  as  if  an  external  force  had  been  applied  to  the  head  to 
turn  it  in  the  same  direction. 

In  DIASTASIS  the  lesion  consists  essentially  of  more  or  less  extensive 
rupture  of  the  ligaments.  It  is  the  same  in  its  forms,  nature,  and 
etiology  as  the  other  varieties,  with  the  exception  of  the  persistent 
displacement  of  the  bones  and  of  the  change  in  the  relations  of  the 
articular  surfaces  to  each  other;  the  displacement  is  either  entirely 
absent  or  is  slight.    A  singular  instance  of  the  production  of  a  diastasis 


1  Volker:  Deutsche  Zeitschrift  fiir  Chir.,  1876,  vol.  vi,  p.  424. 


DISLOCATIONS  OF   THE  CERVICAL   VERTEBRAE. 


585 


by  muscular  action  is  reported  by  Lasalle;!  A  crazy  man,  confined  in  a 
strait-jacket  in  a  chair,  jerked  his  head  violently  backward  and  forward, 
became  at  once  paralyzed,  and  died  a  few  hours  later.  The  autopsy 
disclosed  a  separation  between  the  fifth  and  sixth  cervical  vertebrte. 
with  rupture  of  the  posterior  ligament,  the  interspinous  muscles,  the 
ligamenta  flava,  and  the  intervertebral  disk.  The  possible  production 
of  ha?matomyelia  is  to  be  borne  in  mind. 

Symptoms.  Unilateral  dislocation  forward.  The  posture  of  the  head 
has  varied  so  greatly  in  the  reported  cases  that  it  is  of  no  value  as  a 
symptom.  Not  only  may  the  abduction  of  the  upper  segment  of  the 
column,  which  is  necessary  to  the 

production  of  the  dislocation,  be  Fig.  378. 

almost  entirely  corrected  by  the 
sinking  back  of  the  articular  pro- 
cess of  the  upper  vertebra  into  the 
notch  of  the  lower  one,  but  even  if 
it  persists  it  may  be  so  far  compen- 
sated for  or  obscured  by  flexion  in 
the  occipito-atloid  and  rotation  in 
the  atlo-axoid  articulation,  that  it 
will  not  be  recognized.  The  face 
is,  however,  usually  turned  away 
from  the  side  on  which  the  dis- 
location has  taken  place.  A  pain- 
ful prominence,  swelling,  or  round- 
ing can  be  recognized  on  the  dis- 
located side;  it  is  due,  according 
to  Volker,  to  the  angle  created 
in  the  column,  the  slight  projec- 
tion of  the  transverse  process,  and 
the  contracted  condition  of  the 
muscles.  Observers  dift'er  as  to  the 
condition  of  the  muscles  on  the 
opposite  side,  some  reporting  them 
relaxed,  others  contracted.  The 
deviation  of  the  spinous  process  of 
the  dislocated  vertebra  to  the  side 
of  the  dislocation  is  a  valuable 
sign  when  it  can  be  recognized, 

but  the  depth  at  which  the  third,  fourth,  and  fifth  spinous  processes 
are  placed  is  such  that  their  position  cannot  usually  be  determined  and 
while  that  of  the  second  can  always  be  felt,  its  deviation  ma\'  be 
unrecognizable,  because  the  position  of  the  underlying  ones  with  which 
it  must  be  compared  remains  unknown.  The  projecticm  of  the  Ixxly 
of  the  vertebra  in  the  pharynx  is  sometimes  recognizable  by  the  finger 
introduced  through  the  mouth.  The  last-named  three  signs  are  diag- 
nostic if  fracture  can  be  excluded,  but  as  the  last  two  are  nnrecogniz- 
able  in  many  cases,  the  first,  the  existence  of  a  ])ainful  prominence 
on  the  side  of  the  neck,  is  the  one  ni)()n  which  the  surgeon  will  usually 


Bilateral  dislocation  forward  of  the  fifth  cervical 
vertebra.     (From  a  photograph.) 


1  Lusalle:  Guz.  Medicale,   1S41,  p.  703. 


586  DISLOCATIONS. 

have  to  depend.  Cases  may  occur,  as  they  have  occurred,  in  which 
the  symptoms  are  so  obscure  that  a  diagnosis  between  dislocation  by 
muscular  action  and  muscular  rheumatism  cannot  be  positively  made. 
Under  such  circumstances  the  manipulations  that  would  reduce  a 
dislocation  if  it  were  present  should  be  carefully  made.  If  they  reduce 
the  deformity  and  relieve  the  symptoms  they  both  establish  the 
diagnosis  and  cure  the  patient. 

In  bilateral  dislocation  forward  the  symptoms  vary  greatly.  The 
head  may  be  bent  far  forward  toward  the  chest  with  marked  prominence 
in  the  nape  of  the  neck  of  the  spinous  process  of  the  vertebra  next  below 
the  dislocated  one,  or  it  may  be  bent  backward  or  backward  and  to  one 
side,  with  marked  projection  of  the  trachea  and  perhaps  larynx,  and 
irregularity  in  the  outline  of  the  front  of  the  column  recognizable  by 
palpation  through  the  soft  parts.  The  head  may  be  rigidly  fixed,  or, 
more  rarely,  freely  movable.  These  differences  depend  partly  on  the 
position  of  the  dislocated  bone,  the  presence  or  absence  of  associated 
fracture,  and  the  extent  of  the  injury  to  the  connecting  ligaments, 
partly  on  the  direction  and  character  of  the  dislocating  force,  and  partly 
on  the  contraction  or  relaxation  of  the  muscles  which  control  the 
position  taken  by  the  unaffected  joints  above  the  seat  of  injury.  In  the 
majority  of  cases  the  head  is  bent  forward,  and  an  angle  with  its  apex 
directed  backward  is  formed  by  the  two  segments  above  and  below  the 
dislocation.  Attempts  to  move  the  head  and  pressure  at  the  seat  of 
injury  are  very  painful.  In  these  patients  the  irregularity  in  the  line 
of  the  transverse  processes  may  sometimes  be  recognized  by  the  touch, 
and  if  the  dislocation  is  not  too  low  the  projection  of  the  body  of  the 
vertebra  may  be  felt  in  the  pharynx. 

Of  the  symptoms  of  bilateral  dislocation  backward  nothing  positive 
can  be  said.  In  most  of  the  supposed  cases  the  head  has  been  bent 
backward,  the  face  directed  somewhat  upward,  the  tissues  of  the  front 
of  the  neck  tense,  and  respiration  and  deglutition  somewhat  interfered 
with. 

In  bilateral  dislocation  in  opposite  directions  it  seems  probable  that 
the  head  would  be  fixed  in  rotation,  but  possibly  not  abducted. 

Paralysis,  partial  or  complete,  is  frequently  observed.  Its  immediate 
importance,  its  urgency,  as  a  symptom  varies  accordingly  as  the  dislo- 
cated joint  is  above  or  below  the  point  of  exit  of  the  phrenic  nerve. 
The  fourth  cervical  nerve,  from  which  the  phrenic  mainly  arises, 
though  it  receives  a  branch  also  from  the  third  or  fifth,  leaves  the  ver- 
tebral canal  through  the  foramen  between  the  third  and  fourth  verte- 
brae, but  leaves  the  side  of  the  cord  at  a  somewhat  higher  point.  A 
dislocation  below  the  third  cervical  vertebra  may  cause  paralysis  of  all 
the  accessory  muscles  of  respiration  that  act  by  raising  the  ribs,  but, 
the  diaphragm  continuing  to  act,  prolongation  of  life  is  possible.  If, 
on  the  other  hand,  the  dislocation  is  at  a  higher  point,  and  the  trunks 
going  to  form  the  phrenic  nerve  are  injured  or  the  cord  is  so  compressed 
or  torn  that  the  integrity  of  the  corresponding  fibres  within  it  is  de- 
stroyed, or  tliey  are  all  cut  oflf'  fi'oni  the  respiratory  centre,  then  the 
diaphragm  also,  being  no  longer  iiniervated  by  these  nerves,  immedi- 
ately ceases  to  act,  and  the  individual  dies  asphyxiated.     In  a  few  cases 


DISLOCATIONS  OF   THE  CERVICAL  VERTEBRA.  587 

the  threatening  symptoms  have  been  instantly  reheved  by  changing 
the  position  of  tlie  patient  or  by  systematic  reduction  of  the  disloca- 
tion. In  all  such  threatening  cases  and  in  those  that  are  immediately 
fatal  the  injury  is,  as  a  rule,  at  one  of  the  upper  joints.  In  the  ex- 
ceptions there  have  been  associated  injuries  to  which  the  death  is  to  be 
attributed. 

If  the  paralysis  is  due  to  compression  or  laceration  of  the  cord  it 
may  be  complete  of  both  motion  and  sensation  below  the  point  of 
injury,  or  it  may  involve  only  the  motor  nerves.  It  seems  probal)le 
that  the  partial  paralyses  are  due  to  pressure  not  upon  the  cord  but 
upon  a  nerve  trunk  in  the  intervertebral  foramen.  (See  also  Htema- 
torayelia,  in  Ciiapter  XI.) 

Loss  of  control  over  the  sphincters,  incontinence  of  urine,  and  the 
other  secondary  symptoms  of  injury  to  the  cord  have  been  already 
considered. 

Prognosis.  The  mortality  of  dislocations  of  the  lower  six  cervical 
vertebrse,  excluding  cases  of  diastasis,  cannot  be  positively  determined 
because  of  the  uncertainty  of  the  diagnosis  in  cases  that  recover ;  it  is 
highest,  probably  75  per  cent.,  in  bilateral  dislocation  forward,  and 
much  less  in  the  unilateral.  In  the  fatal  cases  death,  as  a  rule,  comes 
promptly,  within  the  first  week.  Suppuration  has  been  observed  about 
the  seat  of  injury  in  cases  that  remained  unreduced.  In  a  number  of 
cases  gradual  improvement  has  taken  place  in  the  attitude  and  mobility 
of  the  neck.  In  one  reported  by  Walton  ^  of  supposed  dislocation  of 
the  third  cervical  forward  the  symptoms  did  not  become  marked  until 
two  months  after  the  accident  and  then  increased  to  complete  helpless- 
ness ;  fifteen  months  after  the  accident  they  suddenly  improved,  and  a 
month  later  recovery  w^as  complete. 

Treatment.  In  unilateral  dislocation  forward,  at  least  in  those  pro- 
duced by  muscular  action,  Volker  says  reduction  is  usually  easy  and 
free  from  danger.  Mention  has  been  made  above  of  the  case  in  which 
a  boy  reduced  his  own  dislocation  by  resting  his  head  and  shoulder 
against  a  wall  and  pressing  upon  the  prominence  in  the  neck  with  his 
thumb. 

Simple  traction  upon  the  head,  the  counter-extension  being  made  by 
the  weight  of  the  body,  followed  by  rotation  of  the  face  toward  the 
dislocated  side  has  proved  successful,  but  it  seems  better  and  is  gener- 
ally recommended  that  the  articular  process  should  be  freed  by  still 
further  abducting  the  head  and  upper  segment  of  the  column  (away 
from  the  side  of  the  dislocation),  and  then,  when  freed,  should  be 
rotated  backward  into  place.  If  traction  is  used  it  should  be  made  in 
the  direction  of  the  long  axis  of  the  upi)er  segment,  not  in  that  of  the 
lower  one,  for  in  the  latter  case  the  strain  would  come  wholly  or  mainly 
upon  the  untorn  connections  on  the  non-dislocated  side  and  rather  tend 
to  depress  the  dislocated  articular  process  still  further  in  front  of  the 
corresponding  lower  one  than  to  raise  it  above  it. 

Bilateral  didocations  in  opposite  directions  are  to  be  classed  with  the 
preceding  as  dislocations  by  abduction  and  rotation,  and  treated  in  the 
same  manner.  Probably  the  differential  diagnosis  could  not  be  made 
clinically. 

1  Walton:  Boston  Medical  and  Surgiral  Journal,   March  21,   1SS9. 


588  DISLOCATIONS. 

In  bilateral  dislocations  forward  the  methods  that  have  been  employed 
with  success  have  combined  traction  upon  the  head,  either  in  the  sitting 
or  recumbent  posture,  with  pressure  upon  the  front  and  back  of  tlie 
neck  at  suitable  points. 

After  reduction  the  patient  should  be  kept  quiet  for  some  time,  and 
if  reproduction  of  the  dislocation  is  feared  a  retentive  dressing  should 
be  applied.  It  must  be  rigid  enough  to  prevent  any  flexion  of  the 
neck  forward  or  backward,  and,  after  unilateral  dislocation,  should 
include  the  head  so  as  to  prevent  rotation.  Such  a  dressing  can  be 
conveniently  made  with  plaster  of  Paris. 

DISLOCATIONS  OF  THE  DORSAL  VERTEBR-S. 

The  cartilaginous  surfaces  of  the  articular  processes  in  the  dorsal 
region  are  placed  more  nearly  in  a  vertical  plane  than  those  of  the 
cervical  vertebrae  ;  the  superior  ones  look  backward  and  shghtly  up- 
ward and  outward,  the  inferior  ones,  with  the  exception  of  those  of 
the  twelfth,  look  forward  and  slightly  downward  and  inward ;  the  inte- 
rior ones  of  the  twelfth  are  placed  like  those  of  the  lumbar  vertebrae 
and  look  outward  and  somewhat  forward.  This  disposition  does  not 
in  itself  make  dislocation  to  either  side  by  rotation  or  direct  disloca- 
tion backward  with  fracture  difficult ;  dislocation  forward  is  made  pos- 
sible by  flexion  sufficient  to  raise  the  inferior  articular  processes  of  the 
upper  vertebrae  above  the  superior  ones  of  the  lower.  Dislocation 
between  the  twelfth  dorsal  and  first  lumbar  vertebrae  seems  to  be  much 
less  favored  by  the  relations  of  the  processes,  and  yet  this  is  the  point 
in  the  combined  dorsal  and  lumbar  regions  where  dislocation  is  by  far 
most  common.  Blasius^  collected  twenty-two  cases  in  which  the  char- 
acter of  the  dislocation  was  demonstrated  by  autopsy  ;  of  these  one  was 
of  the  third  dorsal  vertebra,  three  of  the  fifth,  one  of  the  sixth,  one  of 
the  ninth,  three  of  the  tenth,  two  of  the  eleventh,  and  eleven  of  the 
twelfth ;  of  the  doubtful  cases  ten  were  thought  to  be  of  the  twelfth, 
four  of  the  eleventh,  and  one  each  of  the  fifth,  eighth,  and  tenth. 

The  observed  varieties  are  the  bilateral  forward  and  backward  with 
about  equal  frequency,  the  bilateral  in  opposite  directions,  and  the 
lateral.  Of  the  latter  there  are  only  two  demonstrated  cases.  Bell  and 
Mohrenstein,  twelfth  dorsal,  and  even  in  these  Blasius  thinks  the  injury 
was  primarily  a  unilateral  dislocation  forward  or  backward,  which  was 
followed  by  bodily  lateral  displacement.  In  the  few  cases  in  which 
the  condition  of  the  adjoining  ribs  is  noted,  these  have  been  found 
sometimes  dislocated  and  sometimes  fractured  not  far  from  the  column. 
The  degree  of  injury  to  the  cord  varies  with  the  character  and  extent 
of  the  displacement.  Other  pathological  conditions  have  been  consid- 
ered above. 

Causes.  The  causes  have  been  forcible  flexion  of  the  trunk  forward 
and  the  direct  action  of  great  violence  upon  the  back  or  side  of  the 
spinal  column,  as  in  the  fall  of  a  heavy  object,  or  the  passage  of  the 
wheel  of  a  wagon  across  the  body. 

Symptoms.     The  symptoms  of  the  dislocation  are  found  in  recog- 

1  Blasius:  Loc.  cit.,  vol.  ciii,  p.  46. 


Dislocations  op  the  lumbar  vertebr.f..         589 

nizable  changes  in  the  position  and  relations  of  the  dislocated  vertebra, 
especially  in  the  prominence  of  its  spinous  process  or  of  the  underlying 
one,  or  in  its  lateral  displacement,  and  in  a  deviation  of  the  column 
which  creates  an  angle  at  the  seat  of  the  dislocation,  the  apex  of  which 
is  usually  directed  backward.  In  some  cases  it  is  noted  that  the  artic- 
ular processes  of  one  or  the  other  of  the  two  adjoining  vertebne  form 
prominences  under  the  skin. 

Excessive  mobility  at  the  seat  of  dislocation  has  also  been  observed 
in  most  cases. 

Paralysis  appears  to  be  more  common  and  more  complete  in  the  for- 
ward than  in  the  backward  dislocations,  and  in  a  few  cases  has  disap- 
peared after  reduction. 

The  symptoms  resemble  so  closely  those  of  fracture  that  the  differ- 
ential diagnosis,  in  the  absence  of  post-mortem  examination,  can  rarely 
be  made  with  certainty.  The  failure  to  obtain  crepitus  is  no  proof  of 
the  absence  of  fracture,  and  when  present  it  may  be  due  to  the  presence 
of  an  associated  unimportant  fracture.  Keduction  and  the  absence  of 
a  tendency  to  reproduction  of  the  deformity  are  the  best  obtainable 
evidence  that  the  injury  was  a  dislocation. 

Prognosis.  The  prognosis,  as  regards  either  the  preservation  of  life 
or  the  full  restoration  of  function,  is  not  favorable.  The  uncertainty 
of  the  diagnosis  in  most  cases  of  survival  and  the  comparative  few- 
ness of  the  cases  deprive  the  percentages  of  value,  and  it  can  only 
be  said  thc.t  the  injury  seems  more  likely  to  prove  fatal  when  it  is 
situated  in  the  upper  part  of  the  region  than  when  in  the  lower,  and 
that  in  quite  a  number  of  cases  more  or  less  complete  recovery  has 
followed. 

Treatment.  Reduction,  by  extension  and  counter-extension  at  the 
hip  and  shoulders,  has  been  tried,  and  sometimes  with  success.  If  it 
is  obtained  the  patient  must  be  kept  absolutely  recumbent  for  several 
weeks,  and  preferably  with  the  trunk  enveloped  in  a  plaster-of-Paris 
dressing,  and  the  same  measures  should  be  employed  even  when  reduc- 
tion has  not  been  eifected,  in  order  to  favor  the  consolidation  of  the 
bones  in  tlieir  new  positions. 

DISLOCATIONS  OF  THE  LUMBAR  VERTEBRA. 

The  possibility  of  the  occurrence  of  pure  dislocation  of  the  lumbar 
vertebrae,  which  has  been  long  in  doubt  because  of  the  close  interlock- 
ing of  the  processes  and  the  strength  of  the  ligaments,  is  proved  by 
two  cases  collected  by  Blasius  and  also,  it  may  be  said,  by  two  others 
in  which  there  was  present  associated  but  unimportant  fracture  of 
some  of  the  processes.  The  first  two  cases  are  those  of  Curling'  and 
Porta.2 

Curling  presented  a  specimen  preserved  in  the  London  Hospital 
Museum  :  the  intervertebral  disk  between  the  third  and  fourth  Imn- 
bar  vertebrae  was  destroyed,  with  slight  s]>lintering  of  the  edge  of  the 
bone  at  one  or  two  places;  the  body  of  the  third  projected  nearly 

*  Curling:  London  Hospital  Reports,  vol.  iii,  p.  355. 
^  Quoted  by  Blasius:  Loc.  eit.,  vol.  ciii,  p.  55. 


590  DISLOCATIONS. 

half  an  inch  in  front  of  that  of  the  fourth,  and  the  articular  processes 
of  the  two  bones  were  separated  to  the  same  distance ;  the  ligaments 
connecting  the  laminae  and  the  spinous  processes  were  stretched  but 
not  materially  torn. 

The  other  two  cases  are  those  of  Keig^  and  Cloquet.^  In  the 
former  a  sailor  twenty-three  years  old  was  crushed  under  a  heavy  iron 
cylinder  which  fell  across  his  back.  The  second  lumbar  vertebra  was 
displaced  backward  seven  lines,  the  upper  articular  process  of  the  third 
becoming  lodged  in  the  notch  of  the  second  ;  the  tip  of  the  right  lower 
articular  process  of  the  second  was  broken  off  but  not  separated  from 
the  rest ;  the  left  transverse  processes  of  the  first  and  second  vertebrae 
were  broken  off  (by  muscular  action,  it  was  thought),  and  the  spinous 
processes  of  the  ninth,  tenth,  and  eleventh  dorsal  vertebrae  and  the 
left  eleventh  and  twelfth  ribs  were  broken.  The  right  sacro-lumbalis 
muscle  was  completely  divided  transversely,  and  the  liver  and  spleen 
were  ruptured. 

In  another  case  Porta  found  at  the  autopsy  a  pure  diastasis  between 
the  third  and  fourth  lumbar  vertebrae,  the  bones  being  separated  a  few 
lines  without  lateral  or  antero-posterior  displacement,  and  all  the  liga- 
ments being  torn  ;  the  spinous  process  of  the  third  was  broken  at  its 
base. 

The  conditions  which  so  effectually  oppose  dislocation  with  or  "with- 
out fracture  are  the  great  breadth,  thickness,  and  elasticity  of  the 
intervertebral  disks,  the  large  masses  of  muscle  that  lie  on  each  side 
of  the  spinous  processes,  and  the  arrangement  of  the  articular  pro- 
cesses by  which  those  of  each  upper  vertebra  are  received  between 
those  of  the  next  lower  and  are  thus  absolutely  prevented  from  mov- 
ing laterally  or  from  being  separated  by  lateral  flexion  without  fracture 
of  one  or  the  other. 

Symptoms.  The  symptoms  are  irregularity  in  the  line  of  the  spinous 
processes,  local  pain,  disability,  and  more  or  less  complete  paralysis  of 
the  parts  below.  As  the  spinal  cord  is  replaced  throughout  the  greater 
part  of  this  section  by  nerve  trunks,  the  cauda  equina,  which  less 
completely  fill  the  canal,  the  paralysis  is  less  likely  to  be  complete  than 
when  the  injury  is  at  a  higher  point,  and  it  is  also  more  easily  recov- 
ered from  if  the  displacement  is  corrected. 

Prognosis.  The  prognosis  is  more  favorable  than  in  dislocations  of 
the  dorsal  and  cervical  regions,  presumably  because  of  the  usual 
absence  of  injury  to  the  cord,  and  the  less  extent  of  the  paralysis;  and, 
while  many  of  the  cases  have  promptly  proved  fatal,  death  has  usually 
been  due  to  associated  injuries. 

Treatment.  In  backward  dislocation  reduction  appears  not  to  have 
been  difhcult ;  it  has  been  obtained  by  pressure  upon  the  projecting 
spinous  process,  with  or  without  forcible  extension  of  the  column.  In 
a  case  reported  by  Harrison,^  dislocation  backward  of  the  third 
lumbar  vertebra,  reduction  was  obtained  with  the  aid  of  anaesthesia  by 
extension  and  counter-extension,   combined  with  moderate  pressure 

'  Keig:  Schmidt's  Jahrbiich.,  vol.  c\ni,  p.  69.     (Blasius  writes  the  name  Keli.) 
2  Blasius:  Loc.  cit.,  from  Journal  des  Difformites,  vol.  i,  p.  453. 
5  Harrison:  Lancet,  1885,  ii,  p.  114. 


DISLOCATIONS  OF   THE  LUMBAR   VERTEBRA.  591 

upon  the  spinous  process,  while  the  patient  was  lying  upon  his  back. 
The  paralysis  began  to  diminish  on  the  following  day,  and  complete 
recovery  followed,  although  a  slight  projection  in  the  line  of  the  column 
persisted.  A  plaster-of-Paris  jacket  was  worn  for  four  and  a  half 
months. 

Possibly  the  plan  recommended  by  some  of  the  older  surgeons,  of 
combining  flexion  forward  with  traction,  would  be  necessary  or  useful 
in  some  cases.  It  could  be  effected  by  placing  the  patient  on  his  belly 
across  the  side  of  a  barrel,  or  by  raising  him  on  a  cloth  passed  under 
his  bellv. 


CHAPTER  XXXIX. 

DISLOCATIONS  OF  THE  STEENUM. 

(See  also  Feactures  of  the  Sternum.) 

Under  this  title  are  included  only  dislocations  of  the  normal 
divisions  of  the  sternum  from  one  another,  not  those  of  the  sternum 
from  the  clavicles  or  from  the  cartilages  of  the  ribs ;  they  are  those  of 
the  body  from  the  manubrium,  and  of  the  ensiform  process  from  the 
body. 

Dislocations   of  the  Body  from  the  Manubrium. 

The  manubrium,  constituting  nearly  the  upper  third  of  the  sternum, 
is  united  to  the  second  piece,  the  body,  by  a  layer  of  interposed  carti- 
lage, sometimes  hyaline,  sometimes  more  or  less  distinctly  fibrous, 
and  sometimes  containing  a  central  synovial  sac.  Henle  speaks  of 
this  central  sac  as  of  rare  occurrence  ;  Maisonneuve  and  Brinton  found 
it  in  about  two-thirds  of  the  cases  examined.  Ossification  of  the  band 
occasionally  takes  place  in  advanced  life ;  the  earliest  age  at  which  it 
has  been  observed  is  thirty-four  years. 

The  second  costal  cartilage  articulates  with  botli  these  segments  of  the 
sternum  at  their  junction.  Although  this  division  of  the  sternum  into 
segments  was  described  by  the  anatomists,  no  account  thereof  appears  to 
have  been  taken  by  surgeons  until,  in  1842,  Maisonneuve^  read  before 
the  Academic  de  M^decine  in  Paris  a  paper  in  which  he  called  attention 
to  the  anatomical  divisions  of  this  bone,  and  reported  two  cases  of  dislo- 
cation of  the  body  from  the  manubrium  which  had  come  under  his 
observation,  and  in  which  he  had  made  the  autopsies.  Earlier  records 
show  several  cases  which  were  doubtless  dislocations,  but  Maisonneuve 
was  the  first  to  separate  them  from  the  class  of  fractures  and  apply  this 
name  to  them. 

The  injury  is  not  a  common  one,  even  if  allowance  is  made  for  the 
probable  description  of  some  as  fractures.  Malgaigne,  in  1855,  could 
collect  only  ten  examples,  although  he  included  in  the  list  several  of 
the  older  cases  reported  as  fractures  ;  Ancelet  ^  collected  sixteen  cases 
of  all  kinds,  Brinton  ^  thirteen  of  dislocation  forward,  and  added  one 
of  his  own.  Gurlt,*  in  his  table  of  fractures  and  disastases  of  the  ster- 
num, has  twenty-nine  cases  classified  as  diastasis  between  the  first  and 
second  pieces,  and  three  between  the  second  and  third.  Adding  to 
these  those  quoted  by  Ancelet,  Brinton,  and  Servier,^  the  list  is  increased 
to  more  than  forty.  Only  one  of  the  patients  was  a  woman,  and  the 
ages  ranged  from  thirteen  to  more  than  sixty-five  years. 

^  Maisonneuve:  Arch.  gen.  de  Med.,  1843,  vol.  xiv.  p.  249. 

*  Ancelet :  Gazette  des  Hopitaux,  1863,  p.  257. 

•^  Brinton  :  American  Journal  of  the  Medical  Sciences,  July,  1867,  p.  39. 

*  Gurlt :  Die  Knochenbriiche,  1862,  vol.  ii.  p.  31. 
^Servier;  Diet.  Encyclopedique,  1884,  art.  Sternum. 

(592) 


DISLOCATIONS  OF  THE  STERNUM.  593 

In  sixteen  the  body  was  completely  dislocated  forward  and  upward 
upon  the  manubrium,  in  three  or  four  backward  ;  in  two  the  dislocation 
was  incomplete  forward,  and  in  one  the  two  segments  were  separated 
longitudinally. 

Causes.  The  injury  has  been  produced  by  direct  and  indirect  vio- 
lence, and,  possibly,  in  one  or  two  cases,  by  muscular  action.  Guines,^ 
in  the  report  of  a  case  of  tetanus  in  a  boy  thirteen  years  old,  states 
that  on  the  seventh  day  he  found  the  breast  elevated,  all  the  false  ribs 
displaced  and  carried  upward,  the  sternum  bent  at  the  junction  of  the 
first  and  second  pieces,  and  forming  with  the  ensiform  process  an 
eminence  three  inches  high.  The  pectoral  muscles  were  forcibly  con- 
tracted, while  those  of  the  abdomen  were,  if  not  in  their  natural  condi- 
tion, at  least  much  relaxed  (compared  with  their  previous  condition). 
On  the  eighteenth  day,  the  tetanus  having  ceased,  it  is  noted  that  the 
deformity  of  the  breast  persisted.  I  understand  this  to  mean  that 
there  was  an  angular  displacement  at  the  junction  of  the  first  and 
second  pieces,  the  apex  being  directed  backward,  and  the  ensiform 
process  distant  three  inches  further  than  usual  from  the  spine. 

In  two  other  cases  muscular  action  may  possibly  have  been  the 
determining  cause,  but  the  mode  of  production  is  obscure;  in  one  of 
them  (Drache,  quoted  by  Malgaigne),  a  young  man  fell  into  a  cellar 
with  some  falling  timber,  which  rested  upon  his  chest ;  while  striving 
to  free  himself  he  felt  a  snap  in  the  region  of  the  sternum,  and  the 
dislocation  was  thought  to  have  been  then  produced.  In  the  other 
(Ancelet),  a  boy  thirteen  years  old  was  exercising  on  parallel  bars  with 
his  chest  bent  forward  ;  his  feet  unexpectedly  touched  the  ground,  and 
a  forward  dislocation,  complete  on  only  the  left  side,  was  produced. 

In  the  case  of  longitudinal  separation  (Aurran  and  David),  the 
patient  fell  from  a  height  of  fifty  feet,  striking  on  his  back  across  a 
low  wall  so  that  his  head  was  on  one  side  and  his  legs  on  the  other. 
He  received  at  the  same  time  a  fracture  of  the  spinous  processes  of  the 
last  two  dorsal  vertebrae,  and  the  dislocation  (a  diastasis)  seems,  there- 
fore, to  have  been  produced  by  hyper-dorsal  flexion  of  the  spinal  col- 
umn, by  which  the  two  segments  of  the  sternum  were  ])ulled  apart. 
The  case  seems,  to  some  extent,  to  confirm  the  theory  of  the  possibility 
of  dislocation  by  muscular  action.     The  patient  recovered. 

In  three  cases  a  forward  dislocation  was  caused  by  violence  received 
directly  upon  the  front  of  the  chest,  presumably  upon  the  manubrium. 
One  patient  (Aurran)  fell  with  a  ladder,  striking  his  chest  against  one 
of  the  rungs  ;  anotlier  (Malgaigne)  fell  against  the  gunwale  of  a  boat ; 
the  third  (Fremey  ^)  was  struck  and  killed  by  the  pole  of  a  wagon. 
Drache's  case  also  is  sometimes  quoted  as  an  example  of  direct  vio- 
lence, and  so  perhaps  may  bo  Richet's,^  in  which  some  boxes  of  soap 
fell  upon  a  man,  and  caused  a  dislocation  backward  of  the  body  upon 
the  manubrium.  Reid's  patient  was  kicked  by  a  mule  ;  the  direction 
of  the  displacement  is  not  mentioned. 

In  Duverney's*  patient  the  injury  was  compound,  and  was  caused 

1  Guines:  Arch.  gen.  de  M6d.,  1829,  vol.  xix.  p.  396. 

'■*  Freiuey :  Bull,  de  la  Soc.  Anatoniique,  1868,  vol.  xiii.  p.  419. 

3  Richet,  reported  by  Slredy  in  Bull,  de  la  Soc.  Auat.,  1857,  vol.  ii.  p.  305. 

1  Duverney  :  Maladies  des  Os,  1751,  vol.  i.  p.  235. 


594  DISLOCATIONS. 

by  the  forcible  compression  of  the  sides  of  the  chest  by  a  falling  stone, 
the  second  piece  being  thrust  forward  (see  Fractures,  p.  191) ;  and  in 
Pitha's  ^  it  was  caused  by  similar  lateral  compression  between  the  buffers 
of  two  railway  cars. 

In  most  of  the  others  the  injury  was  caused  by  a  fall  from  a  height, 
by  which  the  trunk  was  probably  bent  forcibly  forward,  as  shown  in 
several  of  them  by  associated  fracture  of  the  cervical  or  dorsal  verte- 
brae. The  mode  of  production  in  these  cases  appears  to  be  similar  to 
that  by  lateral  compression  of  the  ribs  ;  the  first  and  second  ribs  being 
shorter  and  more  rigid  than  the  others,  the  manubrium  remains  fixed, 
while  the  second  piece  is  pushed  forward  and  upward  by  the  other  ribs 
that  articulate  with  it  and  which  are  themselves  pressed  forward  by 
the  flexion  of  the  spine.  Servier  demonstrated  this  action  upon  the 
cadaver  by  exposing  the  sternum  and  costal  cartilages,  dividing  the 
third,  fourth,  and  fifth  of  the  latter,  and  then  throwing  the  body  back- 
ward from  a  sitting  position  so  as  to  strike  upon  its  shoulders  on  the 
floor ;  the  ends  of  the  ribs  could  be  seen  to  spring  forward  and  inward. 

Pathology.  In  the  common  form,  dislocations  of  the  second  piece 
forward  and  upward,  the  bones  override,  sometimes  as  much  as  an 
inch ;  the  anterior  fibrous  layer  lining  the  bone  is  torn,  the  posterior 
one  stripped  from  the  second  piece.  The  second  costal  cartilages  almost 
invariably  remain  in  contact  with  the  manubrium.  Sometimes  the 
third  and  fourth  have  been  broken. 

In  two  cases,  Nelaton's  and  Ancelet's,  the  dislocation  was  incom- 
plete ;  in  the  latter  the  body  was  turned  about  its  longitudinal  axis 
so  that  its  left  upper  corner  was  elevated  above  the  manubrium  and 
the  second  costal  cartilage  to  a  distance  fully  equal  to  the  thickness  of 
the  bone,  while  its  right  upper  corner  remained  in  place. 

The  dislocations  of  the  body  backward  furnish  two  autopsies.  Saba- 
tier's^  patient  was  an  elderly  man  who,  after  having  been  beaten  with 
the  fists,  was  thrown  into  a  ditch  thirty  feet  deep ;  he  survived  for  a 
week.  The  body  of  the  sternum  was  displaced  2.8  cm.  upward  behind 
the  manubrium ;  there  was  a  large  extravasation  of  blood  under  the 
skin  and  in  the  substance  of  the  right  lung,  which  was  extensively 
bound  down  by  old  adhesions. 

Richet's  patient,  twenty-seven  years  old,  was  thrown  down  upon  his 
back  by  some  heavy  boxes  that  fell  from  a  wagon  upon  his  chest  and 
caused  many  associated  injuries ;  he  died  of  pyaemia  on  the  twenty- 
second  day.  The  body  of  the  sternum  was  displaced  backward  and 
slightly  upward  behind  the  manubrium  ;  the  second  costal  cartilage  on 
the  left  side  remained  attached  to  the  body,  that  of  the  right  side  was 
separated  from  both  body  and  manubrium,  and  its  end  was  free  in  an 
abscess  that  bathed  the  dislocation.  There  was  a  complete  transverse 
fracture  of  the  manubrium  half  an  inch  above  its  lower  end,  and  a 
fracture  of  the  body  without  displacement  at  the  level  of  the  articula- 
tion of  tlie  fourth  costal  cartilages.  There  was  a  compound  fracture 
of  the  left  leg,  and  simple  fractures  of  the  left  third  and  fourth  ribs 
and  of  the  right  radius. 

Tlie  complications  have  been  numerous  and  varied  :  fractures  of  the 

>  Guilt :  Loc.  cit.,  p.  225.  '■'  Gurlt :  Loc.  cit.,  p.  275. 


DISLOCATIONS  OF  THE  STERNUM.  595 

cervical  and  dorsal  vertebrse,  of  the  ribs  and  costal  cartilages,  rupture 
of  the  adherent  lung,  rupture  of  the  lungs  and  heart  (Duvernev). 

Symptoms.  In  the  severe  cases — those  complicated  by  otlier  injuries, 
especially  of  the  spinal  column  and  thoracic  viscera — the  general  symp- 
toms due  to  the  dislocation  may  be  masked  or  increased  by  those  of 
the  other  lesions;  in  general  terms,  the  rational  symptoms  in  forward 
dislocation  are  more  or  less  transient  oppression  of  breathing  and  sharp 
pain  at  the  seat  of  injury,  increased  by  pressure  or  by  movements  of  the 
body  or  head. 

The  neck  and  trunk  are  bent  forward,  the  lower  ribs  appear  promi- 
nent, and  the  upper  ones  depressed.  The  anterior  surface  of  the  ster- 
num presents  a  well-marked  elevation  at  the  level  of  or  just  below  the 
first  intercostal  space,  which  has  a  sharp,  well-defined  upper  margin 
rising  directly  from  the  manubrium  and  is  continuous  below  with  the 
body  of  the  sternum.  The  absence  of  the  second  costal  cartilages 
from  the  upper  corners  of  the  body  makes  it  possible  to  recognize  with 
the  finger  the  shallow,  saucer-like  depression  at  these  points  with  which 
they  articulate.  The  recognition  of  these  depressions,  or  the  distance 
of  the  upper  edge  of  the  projection  from  the  line  of  the  third  ribs, 
will  enable  the  suro;eon  to  distinguish  a  dislocation  from  a  fracture  of 
the  body ;  and  the  presence  of  the  second  costal  cartilages  below  the 
upper  edge  of  the  projection  will  indicate  a  fracture  of  the  manubrium. 

Prognosis.  The  prognosis  is  grave  ;  more  than  half  the  patients  have 
died  of  their  injuries,  though  doubtless  the  fatal  result  is  to  be  attrib- 
uted in  most  of  the  cases  to  the  associated  lesions.  In  the  cases  that 
have  survived  a  failure  to  eifect  reduction  has  not  led  to  any  disability  ; 
one  of  the  patients  in  the  list  had  borne  his  unreduced  dislocation  for 
fifteen  years  without  inconvenience.  Stetter^  mentions,  without  giving 
the  reference,  a  case  observed  by  Audio  of  habitual  dislocation  back- 
ward (or  of  the  manubrium  forward)  which  recurred  every  time  the 
patient  rose  from  the  recumbent  posture  without  supporting  his  head. 

Treatment,  Reduction  is  to  be  made  by  bending  the  trunk  backward 
and  making  pressure  upon  the  projecting  piece  of  the  sternum.  The 
])atient  should  be  placed  upon  his  back  on  a  firm  cushion  or  on  a  table 
with  his  head  and  shoulders  projecting  beyond  its  end,  and  then  the 
head  and  neck  should  be  drawn  backward,  and  counter-extension  made 
on  the  pelvis.  It  is  recommended  also  that  in  dislocation  backward 
the  patient  should  be  encouraged  to  make  full  insj>i rations. 

After  reduction  is  made  a  body  bandage,  or,  better,  a  broad  strip  of 
adhesive  plaster,  should  be  placed  around  the  chest. 

In  case  of  failure  to  reduce  by  these  or  other  simple  means,  resort 
should  not  be  had  to  cutting  operations  unless  grave  indications  due  to 
pressure  upon  the  thoracic  organs  should  exist. 

Pathological  Dislocations.  To  the  three  examples  of  this  kind  (juoted 
by  Malgaigne,  liourneville^  has  added  a  fourth.  In  two,  as  a  result  of 
frequent  pressure  against  the  steriuun,  disj)lacemcnt  took  j)lace  between 
the  first  two  pieces,  one  angular  with  projection  of  the  upper  edge  of 
the  second  piece,  the  other  of  the  second  behind  the  first.     In  the  third 

•  Stetter:  Conipend  voii  den  Liixationen,  188fi,  p.  If). 

^  Bourneville :  Bull,  de  la  Soc.  Anatomique,  1869,  vol.  xiv.  p.  56. 


596  DISLOCATIONS. 

case  the  body  of  the  sternum  and  the  connected  costal  cartilages  could 
be  pressed  back  to  a  depth  of  two  inches.  In  Bourneville's  there  was 
tubercular  suppuration  at  the  junction  of  the  first  two  pieces^  w^ith 
slight  displacement  of  the  second  forward. 

Dislocation  of  the  Ensiform  Process. 

Of  this  injury,  referred  to  by  many  of  the  earlier  writers  as  a  pos- 
sibility, only  five  or  six  more  or  less  well-authenticated  cases  are  on 
record.  They  are  those  of  Martin  and  Billard  quoted  by  Malgaigne, 
Polaillon,^  Gallez  quoted  by  Servier,  and  Hamilton.^  In  addition  may 
be  mentioned  the  reference  made  by  Malgaigne  to  an  example  observed 
in  a  new-born  child  by  Seger^  and  that  to  one  similar  to  Polaillon's 
quoted  by  Mauriceau  in  the  discussion  on  his  case. 

Polaillon's  patient  was  a  woman  thirty-five  years  old,  and  her  injury 
was  caused  apparently  by  tight  lacing  to  conceal  the  enlargement  of 
pregnancv  ;  all  the  others  were  males,  and  their  injuries  were  caused 
by  blows  received  upon  the  epigastrium ;  their  ages  were  eighteen, 
nineteen,  twenty-eight,  and  fifty-three  years. 

No  autopsy  was  had  in  any  case,  and  in  Polaillon's  alone  is  the  con- 
dition described  with  sufficient  detail  to  make  it  reasonably  certain  that 
the  separation  took  place  at  the  line  of  union  between  the  process  and 
the  body  of  the  sternum ;  the  others  may  have  been  fractures  of  the 
process  itself.  In  Polaillon's  the  base  of  the  process  was  displaced 
backward,  and  the  point  looked  directly  forward.  In  Hamilton's,  first 
seen  by  him  twelve  years  after  the  accident,  the  cartilage  was  "  bent 
at  right  angles  with  the  sternum,  pointing  directly  toward  the  spine." 
In  the  other  cases  the  character  of  the  displacement  is  not  fully  de- 
scribed, but  apparently  the  apex  of  the  process  was  directed  back\\ard 
in  most. 

In  three  cases  the  most  prominent  symptom  was  persistent  vomiting, 
which  in  one  (Hamilton's)  recurred  every  five  or  six  days  for  two 
years  and  then  ceased  spontaneously,  in  another  (Martin)  it  was  relieved 
by  grasping  the  process  with  the  fingers  and  drawing  it  forward  into 
place,  and  in  a  third  (Billard),  after  it  had  lasted  a  month  and  threat- 
ened to  prove  fatal,  it  was  relieved  by  drawing  the  process  forward  by 
means  of  a  blunt  hook  introduced  below  it  through  an  incision.  Polail- 
lon's patient  suffered  sharp  pain,  which  was  excited  by  the  pressure  of 
the  clothing  and  the  ingestion  of  food,  and  was  extremely  severe  during 
delivery  ;  reduction  was  impossible,  and  after  a  time  the  inconvenience 
caused  by  it  ceased.  In  Gallez's  case  the  prominence  could  be  reduced 
and  reproduced  with  a  click  by  manipulation  ;  the  patient  suffered  only 
local  pain  and  was  promptly  cured  by  reduction  maintained  by  the 
aid  of  a  small  compress  fixed  over  the  process  by  means  of  adhesive 
plaster. 

1  Polaillon :  Bull,  de  la  Soc.  de  Chirurgie,  1877,  p.  9. 

2  Hamilton  :  Fractures  and  Dislocations,  6th  ed.,  p.  182.  The  account  leaves  it  uncer- 
tain whether  this  was  deemed  a  fracture  or  a  dislocation. 


CHAPTERXL. 

DISLOCATIONS   OF    THE   EIBS   AND    THE    COSTAL    CARTILAGES. 

UxDEE,  this  title  are  included  dislocation  of  the  ribs  at  their  junction 
with  the  vertebrfe,  of  the  ribs  from  the  costal  cartilages,  of  the  carti- 
lages from  the  sternum,  and  of  the  cartilages  of  some  of  the  lower  ribs 
from  one  another. 

The  head  of  each  rib  articulates  with  the  bodies  of  one  or  tM^o  ver- 
tebr£e  by  a  true  joint  containing  one  or  two  synovial  sacs  and  strength- 
ened by  firm  ligaments ;  the  tubercle  and  neck  of  each  rib,  except  the 
eleventh  and  twelfth,  are  united  to  the  transverse  process  of  the  corre- 
sponding vertebra  by  a  synovial  joint  and  ligaments  and  to  the  trans- 
verse process  of  the  vertebra  next  above  by  a  longer  ligament.  The 
union  between  each  rib  and  its  costal  cartilage  is  direct,  without  a 
synovial  sac,  and  is  strengthened  on  the  anterior  surface  by  the  perios- 
teum. The  articulations  between  the  costal  cartilages  and  the  sternum 
are,  with  the  exception  of  the  first,  true  synovial  joints,  sometimes 
double,  surrounded  by  a  capsule  which  is  strengthened  in  fi"ont  and 
behind  to  form  the  anterior  and  posterior  ligaments.  The  seventh  rib 
is  the  lowest  that  articulates  with  the  sternum.  The  fifth,  sixth, 
seventh,  eighth,  and  ninth  costal  cartilages  are  united  with  one  another 
for  a  short  distance  on  their  contiguous  margins  by  true  synovial  joints 
formed  by  slight  projections  on  their  margins  and  surrounded  by 
capsules  which  are  strengthened  by  fibres  derived  from  the  anterior 
intercostal  aponeuroses. 

Dislocation  of  the  Head,  of  the  Rib.     (Luxatio  Costo-vertebralis.) 

The  first  recorded  case,  and  that  a  doubtful  one,  was  reported  in 
1753  to  the  Academic  de  Chirurgie  by  Buttet.  His  patient  was  a 
man  fifty-five  years  old  who  had  been  run  over  by  a  wagon  ;  he  was  so 
fat  and  the  swelling  was  so  great  that  the  outlines  of  the  ribs  could 
not  be  traced,  and  the  diagnosis  was  based  on  the  fact  that  when  press- 
ure was  made  upon  the  front  of  the  chest  the  sixth  rib  on  the  right  side 
could  be  felt  to  move  with  a  very  distinct,  audible  click  which,  moreover, 
was  reproduced  whenever  the  patient  made  a  movement  of  his  trunk. 

The  next  case  was  Hankel's^  in  1834  :  a  young  man  fell  into  a  clay- 
pit  and  received  an  injury  in  the  lower  dorsal  region  ;  he  died  on  the 
fifteenth  day,  and  the  autopsy  showed  fractures  of  the  eleventh  dorsal 
vertebra  and  of  the  twelfth  ril)  on  each  side  and  a  dislocation  of  the 
eleventh  left  rib. 

During  the  next  following  six  years  six  additional  cases  were  re- 
ported, and  the  list  has  not  since  been  added  to  except  by  "Webster's 

1  Haukel :  Gazette  Mcdicale,  1834,  p.  187. 

(  597  ) 


598  DISLOCATIONS. 

case,  the  date  of  occurrence  of  which   is  not  known  but  is  probably 
earlier  than  that  of  the  others,  and  by  Quint.' 

In  all  but  one  of  the  nine  (Kennedy)  the  condition  was  shown  by 
autopsy.  The  causes  were  extreme  violence,  falls  or  blows,  and  in 
one  a  gunshot  wound.  The  ribs  dislocated  were  the  first,  fourth, 
sixth  or  eighth,  and  tenth  once  each ;  seventh,  eleventh,  and  twelfth 
twice  each ;  in  one  case  the  right  eleventh  and  twelfth  and  the  left 
eleventh.  In  two  cases  the  corresponding  vertebra  Avas  broken,  and  in 
four  one  or  more  adjoining  ribs  were  broken.  With  one  exception  the 
patients  died  promptly  or  within  a  few  days  in  consequence  of  asso- 
ciated injuries.  The  exception  was  AVebster's  ;  in  his  the  head  of  the 
seventh  rib  was  found  united  with  the  front  part  of  the  vertebra,  hav- 
ing been  displaced,  it  was  thought,  in  a  fall  from  a  horse  several  years 
before ;  the  injury  was  thought  at  the  time  to  be  a  fracture  of  a  rib. 

Separation  of  the  Ribs  from  the  Costal  Cartilages. 
(Luxatio  Chondro-costalis.) 

Of  this  injury  there  are  only  eight,  possibly  nine,  examples  on 
record,  and  in  only  one  of  these  was  the  condition  demonstrated  by 
autopsy.  Of  the  latter  our  only  knowledge  is  through  the  description 
of  the  specimen  ]iresented  without  history  to  the  Society  Anatomique 
by  Carbonell.^  It  showed  a  separation  of  the  second,  third,  and  fourth 
cartilages  from  the  ribs,  with  fracture  of  the  ossified  union  between 
the  first  rib  and  the  sternum  and  of  the  fifth  costal  cartilage  one  centi- 
metre from  its  outer  end ;  all  five  ribs  were  also  broken  at  their  angles, 
and  the  right  bronchus  Avas  torn  away  from  the  trachea. 

The  other  cases  are  those  of  Chaussier,^  Bell,^  Bouisson;'  De  Kimpe/ 
Bradley,"  Stimson,^  and  B.  F.  Curtis.'' 

In  four  of  the  cases  the  patient  had  been  crushed  between  a  moving 
body  and  a  wall ;  in  two  the  cause  was  a  blow  upon  the  front  of  the 
chest ;  in  one  the  patient  had  long  suffered  with  a  cough  and  had 
thereby  produced  a  hernia  of  the  lung  between  the  eighth  and  ninth 
ribs  on  the  left  side  and  another  between  the  seventh  and  eighth  ribs 
on  the  right  side  at  the  level  of  their  junction  with  the  cartilages, 
accompanied  by  a  separation  between  the  seventh  rib  and  its  cartilage 
on  the  right,  and  between  the  eighth  and  its  cartilage  on  the  left ;  at 
each  of  these  points  the  rib  was  movable  with  crepitus. 

In  Bell's  case  the  ends  of  all  the  ribs  on  both  sides  projected  dis- 
tinctly at  their  junction  with  the  cartilages  ;  in  the  others  the  displace- 
ment of  the  end  of  the  rib  was  in  some  forward,  in  some  backward. 
In  Bradley's  all  the  ribs  from  the  first  to  the  sixth  were  depressed  ;  in 

1  Webster,  Cooper  on  Dislocations  and  Fractures,  Am.  ed.,  1844,  p.  450 ;  Boudet,  Bull, 
de  la  Soc.  Anatomique,  1839,  vol.  xiv.  p.  104;  Alcock,  2  cases,  London  Medical  Gazette, 
1838-39,  vol.  ii.  pp.  586  and  587;  Kennedy,  Dunne,  and  Finnecane,  Dublin  Medical  Press, 
Februarvand  March,  1841,  abstracts  in  Gazette  Med.,  1841,  p.  410;  and  Quint,  Bull. 
Med.  duNord.,  .Tune,  1888. 

2  Carbonell  :  Bull,  de  la  Soc.  Anatomique,  1865,  p.  17. 

3  Chaussier  :  Bull,  de  la  Facuite,  1814,  p.  .50. 

*  Bell:  Surgical  Observations,  1817,  p.  171. 

*  Bouisson  :  Gurlt,  loc.  cit.,  vol.  ii.  p.  251.         ^  De  Kimpe:  Gaz.  des  Hop.,  18.52,  p.  18. 
'  Bradley:  Medical  Record,  August  24,  1890. 

»  Stimson  :  New  York  Medical  Journal.  March  1,  1890.  ^  g.  p.  Curtis :  Ibid. 


DISLOCATIONS  OF  RIBS  AND  COSTAL   CARTILAGES.         599 

mine  the  second  rib  was  dislocated  backward  from  its  cartilage,  and 
the  cartilages  of  the  third  to  the  sixth  forward  from  the  sternnm.  In 
Bouisson's  and  De  Kimpe's  the  fourth  and  fifth  ribs  respectively  were 
displaced  forward. 

The  possible  ninth  case  is  Monteggia's/  a  separation  of  the  second 
and  tliird  costal  cartilages  in  a  very  emaciated  man  seventy  years  old, 
in  consequence  of  a  violent  attack  of  coughing.  Gurlt  says:  "Mon- 
teggia  declares  expressly  that  it  was  not  a  fracture  of  the  cartilage  but 
a  separation  of  the  epiphysis,"  by  which  must  be  meant  a  separation 
at  the  costo-chondral  junction. 

The  injury  is  so  closely  allied  to  fracture  of  the  cartilages  that  the 
reader  is  referred  for  other  details  to  Chapter  XVI. 

Dislocation  of  the  Costal  Cartilages  from  the  Sternum, 
(Luxatio  Chondro-sternalis.) 

Of  this  injury  there  are  fourteen  recorded  examples:  Ravaton, 
Manzotti,  Monteggia,  and  Bell,  quoted  by  Malgaigne ;  Cooper,^ 
Flagg,'^  Wolfenstein,*  Gross,'^  Bennett,*^  Mulvany,^  Blodgett,  two  cases,^ 
Stoner,^  and  mine  quoted  in  the  preceding  section.  There  are,  in  addi- 
tion, one  or  two  cases,  elsewhere  i-eferred  to  (see  Chapter  XXXIX.), 
in  which  separation  of  the  first  and  second  pieces  of  the  sternum  has 
been  accompanied  by  complete  separation  of  the  second  costal  cartilage 
from  the  sternum  on  one  or  both  sides. 

In  three  of  the  cases  (Bell,  Cooper,  and  Blodgett's  second)  the  cause 
appears  to  have  been  traction  exerted  through  the  pectoralis  major,  in 
swinging  dumb-bells,  kneading  bread,  and  exercising  on  parallel  bars ; 
and  possibly  the  cause  was  the  same  in  Blodgett's  first  case,  in  which 
a  man  while  carrying  a  piano  made  a  violent  effort  to  prevent  its  fall. 
In  four  others  the  cause  was  a  fall  or  compression  of  the  chest;  in  the 
remainder  it  is  unrecorded  or  obscure. 

The  fourth  cartilage  was  displaced  singly  forward  in  three  cases, 
forward  in  combination  with  the  fifth  and  sixth  in  two,  and  backward 
with  the  second  and  third  in  one ;  the  third  singly,  the  fifth  and  sixth 
together,  and  the  fifth,  sixth,  and  seventh  together  Mere  displaced  for- 
ward in  two  cases,  the  third  to  the  sixth  forward  in  one,  and  the  first 
and  second  were  together  displaced  forward  and  outward  once  (Blod- 
gett's first).  In  two  cases  it  is  not  stated  which  cartilage  was  dis- 
placed, nor  in  what  direction. 

The  only  autopsy  was  in  Bennett's  case.  The  patient  was  a  woman 
about  fifty-six  years  old  who  had  been  run  over  by  a  cart  and  died  a 
few  days  later  of  pleurisy  and  pneumonia.  The  third  cartilage  on 
the  left  side  was  displaced  forward,  and  there  was  also  fracture  of  the 

^  Gurlt:  Loc.  cit.,  vol.  ii.  p.  250.  ^  Cooper:  Jjoc.  cit.,  p.  451. 

^  Flagg :  Northwestern  Medical  and  Surgical  .Touriuil,  AugiLst,  1871,  quoted  by  Ham- 
ilton. 

*  Wolfenstein  :  Allg.  Wiener  med.  Ztg.,  1873,  No.  44,  quoted  by  Poinsot. 

*  flross :  Surgery,  6th  ed.,  vol.  i.  p.  11.32. 

"  Bennett:  Dublin  Journal  of  the  Medical  Sciences,  1879,  i.  p.  441. 
'  Mulvany  :  Lancet,  1882,  i.  p.  432. 

**  Blodgett:  New  York  Medical  .Journal,  1883,  vol.  xxxviii.  p.  34. 
9  Stoner:  The  Physc.  and  Surg.,  October,  1889, 

42 


600 


DISLOCATIONS. 


second,  third,  fourth,  and  fifth  ribs  on  the  same  side,  and  of  the  second 
to  the  ninth  ribs  on  the  right  side.  The  perichondrium  with  the 
attached  ligaments  was  stripped  clean  off.  The  dislocation  was  reduced 
by  direct  pressure  and  did  not  recur  ;  it  must  be  remembered,  however, 
in  connection  with  this,  that  the  corresponding  rib  was  broken. 

In  the  single  case  of  backward  dislocation  (Mulvany)  the  patient 
was  a  boy  fifteen  years  old,  who  while  steering  a  ship  in  a  heavy  storm 
was  thrown  violently  across  the  deck  by  a  wave  and  struck  upon  the 
back  of  his  left  shoulder  against  the  deck-house.     The  second,  third, 

Fio.  379. 


Dislocation  forward  of  the  third  to  the  sixth  costal  cartilages  from  the  sternum,  and  of  the  first 

rib  backward. 


and  fourth  left  cartilages  were  displaced  backward  behind  the  sternum, 
and  the  sternal  end  of  the  right  clavicle  was  dislocated  forward. 
Reduction  could  be  effected  by  drawing  the  shoulders  backward,  but 
the  displacement  immediately  recun-ed  when  the  traction  ceased.  The 
patient  was  kept  upon  his  back  for  eighteen  days,  and  the  deformity 
was  then  found  to  have  been  much  diminished.  In  two  months  he 
was  again  at  work. 

Usually  there  has  been  sharp  local  pain  at  the  moment  of  the  acci- 
dent, subsequently  excited  by  movements  of  the  thorax  and  by  local 
pressure.     In  one  case  (Mulvany)  there  was  slight  recurrent  haemoptysis. 

The  recognition  of  the  injury  appears  always  to  have  been  easy,  by 


DISLOCATIONS  OF  RIBS  AND   COSTAL  CARTILAGES.         601 

attention  to  the  difference  in  level  between  the  cartilage  and  the 
sternum.  In  only  one  case  (Wolfenstein)  was  it  mistaken  for  a  local 
inflammation. 

Reduction  of  the  forward  dislocations  was  in  every  case  easily  effected 
by  direct  pressure,  but  the  tendency  to  recurrence  was  marked. 

The  best  treatment  would  appear  to  be  the  application  over  the  dis- 
placed cartilage  and  around  the  chest  of  a  broad  strip  of  adhesive 
plaster,  as  in  fracture  of  a  rib,  making  special  local  pressure,  if  neces- 
sary, with  a  compress.     Possibly  a  truss  could  be  used  with  advantage. 

Dislocation  of  One  Cartilage  upon  Another. 
(Luxatio  Chondro-chondralis.) 

Malgaigne  collected  three  supposed  cases,  one  of  which  came  under 
his  own  observation.  I  think  they  should  rather  be  classed  as  dislo- 
cations of  the  ribs  from  the  cartilages,  or  of  the  cartilages  from  the 
sternum,  although  there  was  also  displacement  above  or  below  the  level 
of  the  adjoining  ribs. 

In  the  following  two  the  character  of  the  lesion  is  more  apparent : 

Hochenzegg^  presented  to  the  Gesellschaft  der  Aertze  in  Vienna  a 
patient  thirty  years  old,  who  in  a  fall  broke  the  bond  between  the 
seventh  and  eighth  ribs.  A  year  later  after  a  fit  of  coughing  he  felt 
something  give  away  in  his  side  and  found  a  wide  space  between  those 
ribs. 

Aunis^  found  in  a  man  fifty  years  old  a  dislocation  forward  of  the 
seventh  cartilage  from  the  eighth  ;  it  could  be  reduced  by  pressure,  but 
immediately  recurred.     The  injury  was  caused  by  a  fall  backward. 

^Hochenzegg:  Medical  Press  and  Circular,  Dec.  17,  1890. 
^  Aunis :  Gaz.  Hebdom.,  March  13,  1892. 


CHAPTER  XLI. 

DISLOCATIONS  OF  THE  CLAVICLE. 

Of  the  Sternal    End :  Forward,    backward,   upward — Of  the   Acromial  End . 
Supra-acromial,  subacromial,  subcoracoid — Simultaneous  of  Both  Ends. 

Of  all  dislocations  about  5  per  cent,  are  of  the  clavicle,  those  of  the 
acromial  are  five  times  as  frequent  as  those  of  the  sternal  end.  The 
period  of  greatest  frequency  appears  to  be  between  the  thirtieth  and 
fiftieth  years,  and  during  it  the  injury  is  almost  wholly  confined  to 
males. 

The  dislocation  may  be  of  either  end  or  of  both,  and  occasionally 
both  clavicles  have  been  simultaneously  dislocated. 


Fig.  380. 


1.  DISLOCATIONS  OF  THE  STERNAL  END  OF  THE  CLAVICLE. 

Anatomy.  The  sternal  end  of  the  clavicle  is  so  much  larger  than 
the  clavicular  notch  of  the  sternum  with  which  it  articulates  that  it 
projects  above  it  and  in  front  and  behind.  The  articular  surfaces  are 
separated  from  each  other  by  an  interposed  fibro-cartilaginous  disk,  or 

meniscus,  which  is  most  strongly  at- 
tached above  to  the  upper  edge  of 
the  end  of  the  clavicle,  and  below 
to  the  cartilage  of  the  first  rib.  On 
each  side  of  it  is  a  synovial  cavity. 
The  ligaments  of  the  joint  are  the 
interclavicular,  costo-clavicular,  and 
the  anterior  and  posterior  sterno- 
clavicular. The  interclavicular  liga- 
ment extends  across  from  the  upper 
edffe  of  the  end  of  one  clavicle  to  that 
of  the  other  above  the  interclavicular 
notch  of  the  sternum,  sending  bun- 
dles of  fibres  into  the  meniscus  and 
to  the  top  of  the  sternum.  The  costo- 
clavicular ligament  extends  from  the 
sternal  end  of  the  first  rib  upward 
and  outward  to  the  under  surface  of  the  clavicle  as  far  as  to  the  sub- 
clavian vein,  partly  surrounding  the  inner  end  of  the  subclavius  mus- 
cle but  lying  mainly  behind  it.  It  sometimes  contains  within  itself  a 
bursa  of  considerable  size.  The  anterior  and  posterior  sterno-clavicular 
ligaments  cover  the  joint  in  front  and  behind  respectively,  mainly  con- 
stituting its  capsule.  They  are  short  and  quite  tense. 
(602) 


Frontal  section  through  the  sterno-clav- 
icular joint.  A,  rhomboid  or  costo-clav- 
icular ligament ;  B,  meniscus  ;  C,  inter- 
clavicular ligament.    (Henle.) 


DISLOCATIONS  OF  THE  CLAVICLE.  603 

Motion  is  possible  about  all  the  axes  to  this  extent,  that  the  acromial 
end  of  the  bone  can  be  made  to  describe  a  circle  which  is  the  base  of 
a  cone  having  an  angle  of  60  degrees  at  its  apex  in  the  joint.  Move- 
ment of  the  shoulder  downward  and  backward  is  arrested  by  contact 
of  the  clavicle  with  the  first  rib,  and  if  then  continued  this  point  of 
contact  becomes  the  centre  of  motion,  or  the  fulcrum,  and  the  sternal 
end  of  the  clavicle  is  forced  upward  or  forward  out  of  its  place,  and 
a  dislocation  is  produced. 

Varieties.  The  dislocation  may  be  complete  or  incomplete,  upward, 
forward,  or  backward  ;  and  when  complete  it  is  usually  also  inward, 
toward  the  median  line,  and  when  complete  forward  or  backward  it  is 
usually  also  downward.  Possibly  a  separate  class  of  dislocations, 
upward  and  outward,  should  be  made  of  such  cases  as  those  of  Stokes 
{vide  infra),  in  which  the  cause  is  the  prolonged  action  of  the  sterno- 
cleido-mastoid  muscle  in  forced  inspiration. 

Dislocation  Forward.    (Luxatio  Claviculse  Prsesternalis.) 

This  is  the  most  common  form,  and  is  usually  caused  by  the  shoulder 
being  forced  backward,  or  backward  and  downward.  The  means  by 
which  this  movement  has  been  produced  are  various ;  in  some  cases  it 
has  been  a  fall  upon  the  point  of  the  shoulder  or  upon  the  extended 
hand  ;  in  others,  the  pressure  of  some  heavy  object  upon  the  front  of 
the  shoulder  when  the  body  was  supine,  as  the  wheel  of  a  wagon  or  the 
foot  of  a  horse ;  in  others,  again,  by  the  sudden  slipping  of  a  heavy 
burden  carried  upon  the  back  by  straps  passing  around  the  shoulders. 

Richerand'  reported  a  case  in  which  it  was  caused  in  a  girl  twenty 
years  old  by  the  forcible  approximation  of  her  elbows  behind  her  back, 
and  Boyer  another  in  which  the  shoulders  were  drawn  back  to  give  the 
patient,  a  young  girl,  a  more  erect  and  graceful  carriage.  In  like  man- 
ner, it  has  been  caused  by  the  voluntary  throwing  back  of  the  shoulders, 
as  in  soldiers  at  drill,  and  in  one  case,  Bardenheuer,^  by  the  involun- 
tary effort  made  to  prevent  the  fall  of  a  burden  carried  upon  the  head. 

In  all  of  these  the  mechanism  is  the  same  :  the  outer  end  of  the 
clavicle  is  carried  back  to  the  limit  of  the  normal  range  of  motion,  and 
then  it  either  finds  a  new  centre  of  motion  at  the  point  at  which  it 
comes  into  contact  with  the  first  rib,  in  consequence  of  which  the 
inner  end  is  carried  forward  if  the  movement  is  prolonged,  or  the  ante- 
rior sterno-clavicular  ligament  is  put  upon  the  stretch  and  ruptured, 
and  then  dislocation  takes  place. 

In  a  few  cases  it  has  been  gradually  produced,  apparently  by  relax- 
ation of  the  ligaments  due  to  repeated  slight  strain,  the  dislocation  then 
occurring  whenever  the  arm  was  raised  and  being  spontaneously  reduced 
when  it  was  lowered.  In  one  of  my  cases  both  clavicles  were  thus 
affected.  The  same  condition  of  easy  recurrence  and  reduction  may 
follow  a  primary  traumatic  dislocation. 

In  a  few  cases  the  dislocation  has  been  caused  by  the  ]M-essure  of  an 
aneurism  at  the  root  of  the  neck,  and   in  others'^  by  prolouged,  forced^ 

'  Richerand  :  Quoted  by  Polaillon,  loc.  cit.,  p.  72f». 
2  Bardeuheuer:  Deutsche  (Jhirurfjie,  Lief.  03,  a,  j).  57. 
'  Stokes:  Dublin  Medical  Journal,  18.">2,  vol.  xiii.  p.  459. 


604  DISLOCATIONS. 

inspiratory  efforts.  In  the  latter  (two  cases)  the  dislocations  appear  to 
have  been  primarily  upward,  and  the  displacement  forward  to  have 
been  the  consequence  of  the  elongation  of  the  ligaments.  In  one  of 
them  both  clavicles  were  dislocated. 

Cazin  ^  reported  a  case  in  which  the  dislocation  was  gradually  pro- 
duced in  a  boy  eleven  years  old  who  was  suffering  from  Pott's  disease 
of  the  dorsal  spine  with  angular  deformity  and  retraction  of  the  corre- 
sponding side  of  the  chest,  and  who  had  the  habit  of  resting  on  his 
elbows  in  bed.  Cazin  thought  the  displacement  was  due  to  the  dimi- 
nution of  the  size  of  the  upper  part  of  the  chest,  not  to  the  force 
exerted  through  the  arm. 

Age.  According  to  Bardenheuer,  Fergusson  met  with  a  case  in  which 
the  dislocation  was  produced  in  a  child  during  delivery.  The  next 
earliest  age  at  which  the  injury  has  been  reported  is  ten  months;  it 
was  caused  by  a  fall  from  bed.^ 

Pathology.  The  dislocation  may  be  complete  or  incomplete ;  in  the 
latter  form  the  posterior  portion  of  the  articular  surface  of  the  clavicle 
remains  in  contact  with  that  of  the  sternum,  and  the  anterior  sterno- 
clavicular ligament  alone  is  ruptured.  In  the  former  the  articular 
surfaces  are  completely  separated,  and  the  posterior  edge  of  that  of  the 
clavicle  rests  upon  the  front  of  the  sternum  ;  ordinarily  it  lies  nearer 
the  median  line  and  at  a  lower  level  than  that  of  its  normal  position,  the 
greatest  recorded  displacements  being  one  mentioned  by  Richerand, 
three  inches  downward,  and  one  reported  by  Jousset  ^  in  which  the  end 
of  the  clavicle  lay  upon  the  second  rib.  This  displacement  inward  or 
downward  or  in  both  directions  must  be  secondary  and  due  to  the 
action  of  the  weight  of  the  corresponding  limb  and  to  the  contraction 
of  the  muscles  which  draw  the  shoulder  inward,  downward,  and  for- 
ward when  it  is  deprived  of  its  normal  support,  in  the  same  manner 
and  for  the  same  reasons  as  after  fracture  of  the  clavicle.  The  oppor- 
tunities for  post-mortem  examination  have  been  so  few  that  a  positive 
account  of  the  condition  of  the  ligaments  cannot  be  given.  That  the 
anterior  one  is  ruptured  cannot  be  doubted,  and  it  is  probable  that  the 
posterior  one  also  is  torn,  although  in  some  cases  it  may  only  be  torn 
from  its  attachment  and  left  continuous  with  the  stripped-up  perios- 
teum of  the  posterior  surface  of  the  clavicle.  In  one  case*  all  the  liga- 
ments except  the  anterior  sterno-clavicular  are  described  as  intact ;  the 
meniscus  accompanied  the  clavicle  and  was  partly  torn.  In  a  case 
reported  by  Cloquet^  there  was  found  at  the  autopsy  instead  of  ru})ture 
of  the  posterior  ligament  a  fracture  that  split  the  end  of  the  clavicle 
into  two  parts,  the  posterior  one  of  which  remained  in  place,  while  the 
anterior  one,  continuous  with  the  shaft  of  the  bone  and  capped  by  the 
meniscus,  was  dislocated  forward.  Whether  or  not  the  meniscus  habit- 
ually accompanies  the  end  of  the  clavicle  in  its  displacement  is  not 
known. 

In  the  cases  in  which  the  dislocation  has  been  slowly  produced, 
Stokes's  and  probably  Heusinger's,  the  ligaments  were  found  greatly 

1  Cazin :  Gaz.  des  Hopitaux,  1874,  vol.  xlvii.  p.  507. 

2  T.  E.  Wright :  Boston  Medical  and  Surgical  Journal.  ISSO,  vol.  cii.  p.  333. 

3  Jousset :  Gaz.  Medicale,  1833,  p.  217.  *  Bull,  de  la  Soc.  Anatomique,  1S79,  p.  809. 
5  Cloquet :  Nouveau  Journ.  de  Med.,  1820,  vol.  vii.  p.  248,  quoted  by  Polaillou. 


DISLOCATIONS  OP  THE  CLAVICLE.  605 

elongated  but  not  torn.  Stokes  does  not  mention  the  position  of  the 
meniscus ;  in  Heusinger's  case  it  accompanied  the  clavicle. 

Occasionally  a  portion  of  the  edge  of  the  articular  surface  of  the  ster- 
num or  of  the  clavicle  has  been  broken  off.  The  sternal  portion  of  the 
sterno-cleido-mastoid  may  be  pushed  aside  or  even  torn  away  from  the 
sternum,  perhaps  bringing  with  it  a  scale  of  bone. 

Simultaneous  dislocation  of  the  acromial  end  (vide  infra)  and  frac- 
ture of  the  shaft  have  been  observed  as  complications ;  also  a  similar 
dislocation  of  the  other  clavicle. 

Symptoms.  The  principal  physical  sign  is  the  projection  of  the  end  of 
the  clavicle  and,  if  the  dislocation  is  complete,  its  displacement  toward 
the  median  line  or  downward.  If  the  dislocation  is  incomplete  the 
projection  can  be  made  to  disappear  by  pressing  it  backward,  but  it  is 
likely  to  reappear  when  the  pressure  is  removed.  In  the  complete  dis- 
locations the  weight  of  the  limb,  if  unsupported,  tends  to  bring  the 
shoulder  nearer  the  thorax  and  thus  forces  the  end  of  the  clavicle 
inward  or  downward. 

The  other  symptoms  are  sharp  local  pain,  which  abates  in  a  day  or 
two,  depression  of  the  shoulder,  inclination  of  the  head  toward  the 
injured  side,  and  inability  to  raise  the  arm. 

The  local  swelling  may  be  so  great  as  to  mask  the  position  of  the 
bone,  and  if  crepitus  should  be  present  the  injury  may  be,  as  it  has 
been,  mistaken  for  fracture.  Another  error  of  diagnosis  has  been 
to  mistake  the  dislocated  end  for  an  exostosis ;  and,  conversely,  hyper- 
trophy of  the  bone  has  been  mistaken  for  a  dislocation. 

Prognosis.  The  prognosis  is  unfavorable  as  regards  the  complete 
correction  of  the  deformity,  but  favorable  in  respect  of  the  restoration 
of  function.  In  almost  all  the  reported  cases  projection  of  the  end  of 
the  bone,  to  a  greater  or  less  extent,  has  persisted,  but  the  patients  have 
been  able  to  use  the  arm  freely  and  with  no  sense  of  loss  of  power, 
even  when  the  dislocation  has  remained  complete.  In  some  the  con- 
dition of  "habitual"  or  "recurrent"  dislocation  ensues,  the  bone 
slipping  out  of  place  whenever  certain  movements  of  the  arm  are 
made.     The  discomfort  caused  thereby  may  be  very  great. 

Treatment.  Reduction  is  effected  by  drawing  the  shoulder  outward 
and  slightly  backward  and  making  pressure  backward  on  the  dislocated 
end  after  it  has  been  thus  brought  opposite  the  joint.  Hamilton  failed 
in  two  cases  to  effect  reduction,  but  I  have  met  with  no  other  reported 
failures.  The  reduction  is,  however,  the  least  part  of  the  treatment ; 
the  difficulty  is  to  keep  the  bone  in  its  place.  The  anatomical  rela- 
tions and  the  mode  of  production  suggest  that  this  would  best  be 
effected  by  keeping  the  shoulder  well  forward  until  after  repair  of  the 
torn  ligaments  shall  have  taken  place,  and  I  can  account  for  the  fail- 
ures imder  this  plan,  which  was  recommended  by  Velpeau  and  J\Ial- 
gaigne,  only  by  supposing  that  it  was  not  properly  carried  out.  I  have 
found  it  easy  to  maintain  the  position  by  a  figure-of-eight  bnndage  about 
both  shoulders,  the  turns  crossing  in  front  of  the  chest,  and  also  by  a 
plaster-of- Paris  dressing  about  the  shoulder  and  chest.  In  the  simpler 
cases  it  is  sufficient  to  immobilize  the  shoulder  without  drawing  it  for- 
ward, and  to  prevent  the  elevation  of  the  arm. 


606  DISLOCATIONS. 

Moulded  pads  of  leather^  gutta-percha,  or  plaster  of  Paris  covering 
the  end  of  the  bone  and  the  adjoining  part  and  held  in  place  by  band- 
ages about  the  chest  have  given  good  results. 

Direct  pressure,  usually  in  conjunction  with  fixation  of  the  shoulder, 
has  been  applied  in  a  great  variety  of  ways,  of  which  the  simplest, 
Avhich  may  serve  also  as  the  type,  was  that  employed  by  Nelaton.  He 
used  an  ordinary  spring-truss,  placing  one  of  its  pads  upon  the  sternal 
end  of  the  clavicle  and  the  other  between  the  shoulder-blades,  and 
carrying  the  spring  under  the  axilla  of  the  uninjured  side.  The  objec- 
tion to  the  use  of  pressure  arises  from  the  probability  of  irritating  the 
skin  or  even  causing  a  slough  at  the  point  at  which  it  is  applied. 
Combined  with  rest  in  bed  upon  the  back  and  a  good  position  of  the 
shoulder,  the  maintenance  of  the  pressure  for  a  week  has  proved  suffi- 
cient to  prevent  recurrence,  although  not  entirely  to  overcome  the  pro- 
jection. 

In  a  case  in  which  the  total  correction  of  the  displacement  would 
be  important,  the  patient  should  be  kept  in  bed  upon  the  back,  in  order 
to  diminish  the  tendency  to  reproduction  of  the  deformity  created  by 
the  weight  of  the  shoulder  when  the  body  is  erect,  and  frequent  inspec- 
tion should  be  made  to  determine  the  efficiency  of  the  measures. 
Should  all  other  means  fail,  digital  pressure  might  be  maintained 
for  a  week  or  ten  days.  The  dressings  should  be  worn  for  at  least  a 
month. 

Habitual  or  recurrent  dislocation  has  been  successfully  treated  by 
prolonged  retention,  and  in  two  cases  by  myself^  by  peri-articular  injec- 
tions of  alcohol ;  a  few  drops  of  alcohol  are  injected  with  a  hypodermic 
syringe  into  the  tissues  in  front  of  and  below  the  joint,  and  the  arm 
immobilized,  or,  at  least,  elevation  of  the  elbow  is  avoided.  In  one 
case  I  made  four  injections  at  intervals  of  about  a  week;  in  the  other 
one  injection  was  sufficient. 

Dislocation  Backward.    (Luxatio  Claviculae  Retrosternalis.) 

This  dislocation,  the  second  in  order  of  frequency  of  those  of  the 
sternal  end,  may  be  produced  directly,  by  a  force  acting  from  before 
backward  upon  the  end  of  the  bone,  or  indirectly,  by  a  force  that  presses 
the  shoulder  forward  and  inward.  The  latter  is  the  more  frequent. 
In  the  few  recorded  cases  of  dislocation  by  direct  violence  the  cause  has 
been  such  as  a  fall  of  the  patient  forward,  striking  upon  the  clavicle, 
or  the  fall  upon  him  of  a  stone,  or  the  passage  across  his  chest  of  the 
wheel  of  a  wagon.  In  the  dislocations  by  indirect  violence  the  patient 
has  commonly  been  caught  between  two  bodies,  as  the  pole  of  a  wagon 
and  a  wall,  or  the  side  of  a  railway  car  and  a  wall,  or  between  two 
boats,  in  such  a  way  that  the  shoulder  has  been  pressed  forward  and 
inward. 

The  dislocation  may  be  complete  or  incomplete. 

Pathology.  The  only  recorded  cases  in  which  direct  inspection  of 
the  parts  has  been  made  are  those  of  Tyrrell  ^  and  Bennett.^     In  the 

^  Stimson  :  New  York  Medical  Journal,  November  23,  1889. 
2  Tyrrell  :  St.  Thomas's  Hospital  Eeports,  ]836,  vol.  i.  p.  261. 
*  Bennett :  Dublin  Journ.  Med.  Sciences,  1881,  vol.  Ixxi.  p.  444. 


LTSLOCATIONS  OF  THE  CLAVICLE,  G07 

former  a  compound  dislocation  was  caused  by  the  point  of  a  pickaxe 
entering  below  the  end  of  the  bone  ;  the  pectoralis  major  was  freely  torn 
from  its  attachment  to  the  clavicle,  but  in  all  probability  this  was 
mainly,  if  not  entirely,  the  result  of  a  direct  action  upon  it  of  the 
point  of  the  pickaxe,  and  is  not  a  common  feature  of  the  dislocation. 
The  meniscus  remained  attached  to  the  sternum,  and  the  end  of  the 
clavicle  could  be  easily  felt  by  the  finger  in  the  wound. 

In  the  second  case  the  patient  was  caught  between  a  wall  and  a  rail- 
way car  and  rolled  along  for  some  distance.  The  sternal  end  of  the 
riglit  clavicle,  accompanied  by  the  meniscus,  was  dislocated  backward, 
and  the  cartilages  of  the  f  rst,  second,  third,  and  fourth  ribs  of  the  same 
side  were  broken. 

The  end  of  the  bone  is  displaced  inward  or  inward  and  downward, 
and  it  is  generally  stated  that  it  lies  between  the  trachea  and  the  sterno- 
hyoid and  sterno-thyroid  muscles,  but,  in  the  absence  of  direct  proof 
of  this,  1  am  disposed  to  believe  rather  that  it  may  lie  between  the 
latter  muscle  and  the  sternum,  and  below  the  former,  for,  it  will  be 
remembered,  the  sterno-hyoid  arises  in  part  from  the  posterior  ligament 
of  the  joint  and  frequently  from  the  clavicle  itself,  and  the  sterno-thyroid 
lies  behind  the  other  and  has  its  origin  as  low  even  as  the  cartilage  of 
the  second  rib.  Possibly  the  difference  noted  in  the  direction  of  the 
displacement,  inward  in  some,  inward  and  downward  in  others,  may 
depend  upon  varying  relations  between  the  bone  and  these  muscles. 

Whatever  the  relations  between  these  parts  may  be,  the  end  of  the 
bone  frequently  presses  upon  the  trachea  and  thereby  causes  more  or 
less  dyspnoea,  or  upon  the  oesophagus  and  causes  dysphagia.  Of  six- 
teen cases  analyzed  by  Polaillon'  dyspnoea  was  present  in  six  and  dys- 
phagia in  three.  The  venous  congestion  of  the  face  and  neck  coexisting 
with  the  dyspnoea  has  been  sometimes  attributed  to  pressure  upon  the 
brachio-cephalic  vein,  but  although  the  region  into  which  the  end  of 
the  bone  is  displaced  is  occupied  by  most  important  vessels  and  nerves, 
the  recorded  histories  do  not  show  that  they  have  ever  been  seriously 
pressed  upon. 

Beside  the  complication  of  fracture  of  the  cartilage  of  the  first  four 
ribs  in  Bennett's  case  mentioned  above,  fracture  of  the  first  rib  has  been 
noted  in  a  case  reported  by  Dr.  N.  C  Morse :  ^  the  patient  was  a  girl 
eight  years  old  who  had  been  run  over  by  a  wagon  and  had  received  a 
dislocation  backward  of  the  sternal  end  of  the  left  clavicle,  with  frac- 
ture of  the  first  rib,  and  a  dislocation  "  outward  "  (forward  ?)  of  the 
sternal  end  of  the  right  clavicle.  Apparently  the  wheel  had  crossed 
the  left  clavicle  and  chest.  There  was  great  dyspnoea  and  marked 
venous  congestion  of  the  face  and  neck  which  disappeared  on  reduction 
of  the  ilislocation.  The  child  recovered.  Geissler  ^  reports  a  case  in 
which  the  sternal  ends  of  both  clavicles  were  dislocated  backward  by  a 
fall  npon  the  back  of  the  head  and  shoulders.    Beduction  was  incomplete. 

Symptoms.  The  absence  of  the  end  of  the  clavicle  from  its  articu- 
lation, and  its  position  behind  the  sternum  are  recognizable  bv  inspec- 
tion and  jxilpation,  the  course  of  the  bone  can  be  seen  and  felt  to  pass 

.    •  Polaillon  :  Diet.  EncyclopL-dique  dcs  Sciences  Med.,  art.  Clavicule. 
'•^  Morse:  Cincinnati  Medical  News,  ]«77,  vol.  vi.  p.  819. 
'Gei.ssler:    Zcntralhlatt  fiirCiiir.,  liHK!,  p.  709. 


608  DISLOCATIONS. 

inward  behind  its  normal  position,  and  the  cavity  and  border  of  the 
articnlar  snrface  of  the  sternnm  can  be  traced  with  the  finger. 

Tiie  shoulder  hangs  a  little  forward  and  nearer  the  chest ;  sharp  pain, 
increased  by  movements  of  the  arm  or  liead,  is  felt  at  the  seat  of  injury, 
but  usually  is  prompt  to  disappear.  These  voluntary  movements  are 
restricted  or  abolished  by  the  pain. 

Disturbance  of  respiration  by  compression  of  the  trachea  has  been 
noted  in  only  about  one-third  of  the  cases,  and  may  be  slight  or  so 
severe  as  to  threaten  suffocation.  Ordinarily  it  lasts  for  only  a  short 
time,  even  if  the  dislocation  remains  unreduced. 

Difficulty  in  swallowing  has  been  less  frequently  noted  than  dysp- 
noea (three  times  in  sixteen  cases). 

Prognosis.  The  prognosis  is  favorable  as  regards  the  re-establish- 
ment of  function  even  if  the  dislocation  is  not  reduced,  and  reduction 
is,  as  a  rule,  easy,  and  retention  more  complete  than  after  dislocation 
forward. 

Treatment.  Reduction  can  commonly  be  effected  by  drawing  the 
shoulder  outward  and  backward,  and  this  seldom  requires  more  force 
than  the  surgeon  himself  can  exert  without  assistance.  In  one  case 
Lenoir  was  obliged  to  provide  counter-extension  by  a  bandage  carried 
around  the  chest  and  made  fiist  to  the  wall,  and  extension  by  another 
bandage  passed  around  the  upper  ])art  of  the  arm  and  drawn  upon  by 
two  assistants  while  a  third  held  the  elbow^  near  the  side.  In  another 
of  his  cases  one  assistant  placed  his  knee  against  the  patient's  back  and 
drew  his  shoulder  backward  while  a  second  assistant  held  up  the  chin, 
and  Lenoir  passed  his  finger  down  behind  the  end  of  the  clavicle  and 
pressed  it  forward.  Reduction  took  place  promptly  and  with  a  distinct 
snap. 

Recurrence  of  the  displacement  should  be  opposed  by  dressings  that 
hold  the  shoulder  back  and  down.  The  necessity  exists  as  in  disloca- 
tion forward  to  examine  the  joint  frequently  with  the  object  of  promptly 
detecting  and  correcting  any  faulty  position,  and  to  wear  the  dressings 
for  several  weeks. 

Dislocation  Upward.    (Luxatio  Claviculse  Suprasternalis.) 

The  first  recorded  case  of  this  form  of  dislocation  was  published  by 
Duverney^  in  1751,  the  next  was  observed  by  Sedillot"  in  1835,  and 
Malgaigne  in  1855  could  collect  only  five  cases.  The  number  is  now 
increased  to  about  twenty,'^  with  two  autopsies,  Duverney's  and  R.  W. 
Smith's.'^  It  differs  from  the  forward  dislocation  in  that  the  bone  lies 
behind  the  sternal  portion  of  the  sterno-cleido-mastoid  muscle  instead 
of  in  front  of  and  below  it. 

The  cause  in  the  sudden,  traumatic  cases,  is  the  forcible  depression 

of  the  shoulder  and  the  acromial  end  of  the  clavicle,  by  which  the 

upper  portion  of  the  capsule  is  torn  and  the  end  of  the  bone  lifted  out 

of  tlie  joint ;  then,  the  force  continuing  to  act  and  pressing  the  shoulder 

'  Duverney  :  Traite  des  Maladies  des  Os,  vol.  i.  p.  201. 
2  Scdillot :  Contributions  a  la  Chirurgie,  1868,  vol.  i.  p.  261 . 

'For  the  bibliography  see  Malgaigne,  Hamilton,  and  Polaillon,  and  cases  here  men- 
tioned passim,  and  Evans,  Gaillard's  Medical  Journal,  ]March,  1888. 
*  E.  W-  Smith :  Dublin  Journal  Medical  Sciences,  1872,  vol.  ii.  p.  450. 


DISLOCATIONS  OF  THE  CLAVICLE. 


cm 


inward  towai'd  the  chest,  the  bone  is  forced  inward  to  or  beyond  the 
median  line  and  sometimes  upward  so  far  even  as  to  rest  upon  the  ante- 
rior surface  of  the  hirynx.  A  unique  mode  of  production  was  reported 
by  Dr.  A.  N.  Blodgett/  The  patient  was  carrying  one  end  of  a  piano 
when  the  two  men  wlio  were  carrying  the  other  end  allowed  it  to  fall. 
The  patient  felt  a  sharp  pain  at  the  root  of  the  neck  and  front  of  the 
chest,  and  it  was  found  that  the  sternal  end  of  the  right  clavicle  had 
been  dislocated  upward  and  inward  and  that  the  first  and  second  costal 
cartilages  of  the  same  side  had  been  dislocated  from  the  sternum  for- 
ward  and  outward. 

In  Duverney's  case  all  the  ligaments  were  torn  and  the  periosteum 
was  stripped  from  the  end  of  the  clavicle  ;  proliably,  therefore,  the 
meniscus  remained  attached  to  the  sternum.  In  R.  W.  Smith's  case, 
the  end  of  the  left  clavicle  rested  on  the  u])per  border  of  the  sternum 
in  contact  with  the  right  sterno-cleido-mastoid,  having  passed  behind 
the  sternal  portion  of  the  left  sterno-cleido-mastoid  and  in  front 
of  the  sterno-hyoids.  The  anterior  and  posterior  sterno-clavicular 
ligaments  and  the  costo-clavicular  were  torn ;  the  meniscus  accom- 
panied the  clavicle.  The  subclavius  muscle  was  relaxed  but  not  torn. 
There  were  dyspnoea  and  dysphagia  ;  death  was  the  result  of  associated 
injuries. 

Fig.  381. 


Dislocation  upward  of  the  sternal  end  of  the  clavicle.    (R.  W.  SjriTH.) 

In  a  case  reported  by  Stokes,^  and  mentioned  above,  the  dislocation 
is  described  as  forward  and  upward,  and  the  joints  as  being  so  loose 
that  the  sternal  end  of  each  clavicle  could  be  easily  moved  in  any 
direction;  this  condition  had  been  produced  by  the  "  powerful  action 
of  the  sterno-cleido-mastoid  muscles"  in  forced  inspiratory  efforts  pro- 
voked by  great  dyspnoja  due  to  ascites.  At  the  autopsy  the  ligaments 
were  found  to  be  greatly  stretched,  the  sterno-clavicular  being  half  as 
long  again  as  natural  and  the  rhomboids  (costo-clavicular)  also  elon- 

'  Blodgett :  New  York  Medical  Journal,  1883,  vol.  xxxviii.  p.  34. 
'Stokes:  Dublin  Medical  Journal,  1852,  vol.  xiii.  p.  459. 


610 


mSLOCATIOKS. 


gated.  The  relations  of  the  end  of  the  clavicle  to  the  sternal  portion 
of  the  sterno-cleido-raastoid  are  not  stated,  and  it  remains  uncertain, 
therefore,  whether  the  case  properly  belongs  in  the  class  of  dislocations 
upward. 

Symptoms.  If  the  dislocation  is  i)icomplete  the  only  symptoms  are 
the  projection  of  the  end  of  the  clavicle  above  its  normal  position,  and 
the  local  pain  increased  by  movements  of  the  head  and  ai'ms. 

The  svmptoms  of  the  complete  form  are  the  recognizable  displace- 
ment of  the  end  of  the  bone  inward  and  upward  to  a  variable  distance, 
its  position  behind  the  sternal  portion  of  the  sterno-cleido-mastoid  of 
the  same  side,  the  depression  of  the  shoulder,  and  its  approximation  to 
the  chest ;  local  pain,  sometimes  dyspnoea  and  dysphagia,  inhibition  of 
voluntary  movements  of  the  shoulder  and  head  because  of  pain,  and 
sometimes  the  impossibility  of  passively  raising  the  shoulder.  The 
emptiness  of  the  clavicular  notch  of  the  sternum  may  perhaps  be 
recognized  by  palpation. 

Treatment.  Reduction  is  eflPected  by  drawing  the  shoulder  outward 
and  making  direct  pressure  downward  and  outward  upon  the  sternal 
end  of  the  clavicle,  but  here  again  the  chief  difficulty  is  to  prevent 
recurrence.  Fixation  of  the  shoulder  by  various  dressings  and  the 
recumbent  position  to  avoid  the  depression  of  the  shoulder  by  the 
action  of  gravity  have  Ijeen  employed  wit-h  a  fair  measure  of  success, 
the  resulting  deformity  being  slight  and  the  re-establishment  of  the 
usefulness  of  the  arm  complete. 

2.  DISLOCATIONS  OF  THE  ACROMIAL  END  OF  THE  CLAVICLE. 

Anatomy.  The  clavicle  is  attached  to  the  scapula  at  two  points, 
namely  :  at  its  extreme  end  to  the  inner  margin  of  the  acromion  by  the 
acromio-clavicular  joint,  and  further  inward  to  the  coracoid  process  by 
the   coraco-clavicular  ligaments.     The  articular  surfaces  forming  the 


Fig.  382. 
Trapezoid 


Ligaments  unitin 


acromio-clavicular  joint  are  flat  and  oval  in  shape,  the  long  axis  being 
antero-posterior,  and  the  upper  edge  of  the  end  of  the  chivicle  rises  to 
a  variable  distance  above  the  upper  surface  of  the  acromion.     The 


DISLOCATIONS  OF  THE  CLAVICLE.  611 

articular  surfaces  are  separated  in  part,  sometimes  completely,  by  an 
interposed  meniscus  of  fibrous  tissue,  wedge-shaped,  with  its  base 
directed  upward  and  attached  to  the  broad,  strong  superior  ligament; 
the  inferior  ligcnaent,  usually  much  thinner  than  the  superior,  closes  the 
joint  below.  Tiie  coraco-clavicular  ligament  is  composed  of  two 
portions,  the  postero-internal,  or  conoid,  and  the  antero-external,  or 
trapezoid. 

Complete  dislocation  involves  not  only  the  rupture  of  the  ligaments 
of  the  joint  proper,  but  also  of  the  conoid  and  trapezoid  ligaments  to 
a  greater  or  less  extent.  The  joint  alloM's  motion  in  all  directions,  the 
extreme  ranges  being,  according  to  Albert,  20  to  30  degrees  in  the 
horizontal  plane,  and  60  to  70  degrees  in  the  vertical  plane ;  and  its 
dislocation  appears  to  be  commonly  eflFected,  not  by  extending  the 
movement  of  the  joint  beyond  its  normal  limit,  but  by  direct  displace- 
ment of  one  bone  upon  the  other. 

The  clavicle  may  be  displaced  upward,  supra-acromial  dislocation, 
or  downward  and  backward,  subacromial  dislocation,  or  downward  and 
forward  under  the  coracoid  process,  subcoracoid  dislocation.  The  first 
is  by  far  the  most  common  ;  the  last  has  been  observed  by  only  two 
surgeons,  one  of  whom  reported  five  cases. 

Some  authors,  following  the  system  of  nomenclature  used  in  the  dis- 
location of  other  joints,  term  them  dislocations  of  the  scapula,  but  the 
innovation  has  not  made  its  way. 

Supra-acromial    Dislocation.      (Luxatio  Claviculae  Supra- 

acromialis.) 

The  dislocation  may  be  complete  or  incomplete ;  in  the  latter  the 
clavicle  is  displaced  upward  to  a  distance  equal  or  nearly  equal  to  the 
vertical  diameter  of  its  articular  surface  ;  in  the  former  the  separation 
of  the  articular  surface  is  complete,  and  there  is  an  additional  displace- 
ment outward  over  the  acromion,  or  outward  and  backward,  or  to  a 
greater  distance  upward. 

The  cause  is  usually  a  blow  received  upon  the  point  of  the  shoulder 
and  directed  downward  with  an  inclination  inward,  forward,  or  back- 
ward. The  vigorous  contraction  of  the  trapezius  by  which  the  clavicle 
is  prevented  from  accompanying  the  acromion  in  its  descent  seems  to 
be  an  important,  perhaps  an  essential,  factor  in  the  production  of  the 
lesion,  the  alternative  factor  that  has  been  suggested,  arrest  of  the 
descent  of  the  clavicle  by  contact  with  the  first  rib,  seems  more  likely 
to  produce  dislocation  of  the  sternal  end  of  the  bone.  Malgaigne 
found  in  one  case  marked  tenderness  of  the  trapezius  and  sterno-eleido- 
mastoid  muscles,  and  cites  the  fact  as  proof  of  the  correctness  of  this 
theory  in  some  cases.  The  absence  of  such  tenderness  in  other  cases 
should  not,  I  think,  be  deemed  opposing  evidence,  for  an  efficient  con- 
traction not  followed  by  injury  of  the  muscle  is  easily  conceivable.  A 
case  reported  by  Cloquet,^  and  sometimes  cjuoted  as  an  exam])le  of  dis- 
location by  direct  violence,  seems  clearly  to  indicate  the  important  part 
played  by  muscular  action  :  A  man  who  was  carrying  a  beam  upon  his 
\  Cloquet :  Jourual  Hebdomadaire,  1830,  vol.  vii.  p.  400,  quoted  by  Malgaigne. 


612  DISLOCATIONS. 

shoulder  made  a  violent  eflPort  to  keep  it  from  falling,  and  found  he  had 
thereby  produced  a  dislocation.  Polaillon  ^  mentions  a  case  communi- 
cated to  him  by  Dolbeau  in  which  the  dislocation  was  caused  in  a 
woman  by  an  attempt  to  strike  a  child.  In  such  a  case  the  momen- 
tum of  the  arm  presumably  takes  the  place  of  the  more  common  exter- 
nal violence  received  upon  the  shoulder.  In  one  of  my  cases  the  dis- 
location was  caused  by  a  blow  from  a  falling  brick,  which  also  broke 
the  acromion  at  its  base  and  dislocated  the  humerus.  (See  Chapter 
XLII.) 

A  unique  case  in  which  the  dislocation  was  caused  by  a  blow 
received  upon  the  clavicle  from  below  upward  is  reported  by  Hamil- 
ton ;^  a  bolt  three-quarters  of  an  inch  in  diameter  was  driven  through 
the  skin  on  the  anterior  margin  of  the  left  axilla,  breaking  the  first 
rib,  severing  the  coraco-clavicular  ligaments,  and  forcing  the  clavicle 
upward  from  its  place. 

Malgaigne  reports  a  case  in  which  the  injury  was  apparently  caused 
by  a  fall  upon  the  elbow. 

Pathology.  Our  knowledge  of  the  character  and  extent  of  the 
laceration  of  the  ligaments  is  derived  almost  exclusively  from  clinical 
observation  and  experiments  upon  the  cadaver,  for  there  are  only  two 
autopsies  and  one  museum  specimen.  One  autopsy,  reported  by  Mal- 
gaigne,^ was  in  a  case  of  incomplete  dislocation  and  showed  that  thd 
articular  facet  of  the  clavicle  had  not  entirely  left  that  of  the  acromion  ; 
the  superior  acromio-clavicular  ligament  was  only  stretched  or  perhaps 
slightly  torn  away  from  the  acromion,  and  the  inferior  one  was  in  great 
part  ruptured ;  on  the  other  hand,  the  strong  coraco-clavicular  liga- 
ments were  torn  entirely  across.  There  were  other  and  more  serious 
associated  lesions,  among  them  a  comminuted  fracture  of  the  body  of 
the  scapula  on  the  same  side. 

The  second  autopsy,  made  and  reported  by  Dr.  P.  R.  Bolton,^  was 
in  a  case  of  my  own  at  the  Hudson  Street  Hospital,  April,  1902.  Both 
acromio-clavicular  ligaments  were  "torn  across,  and  the  conoid  and 
trapezoid  ligaments  were  torn  away  from  the  coracoid  process. 

The  museum  specimen  is  one  preserved  in  St.  Thomas's  Hospital 
and  mentioned  by  Sir  Astley  Cooper.^  The  patient  was  a  man  sixty 
years  old  who  died  of  pulmonary  disease  seven  weeks  after  the  receipt 
of  the  injury.  The  account  from  which  I  quote  states  only  that  "the 
clavicle  was  found  dislocated  at  its  scapular  extremity,  and  projected 
considerably  over  the  spine  of  that  bone.  The  acromion  process,  just 
where  the  clavicle  is  united  with  it,  was  broken  oif."  Malgaigne, 
quoting  apparently  from  some  other  account,  says  that  Cooper  supposed 
that  all  the  acromial  and  coracoid  ligaments  must  have  been  torn.  He 
adds  that  this  is  what  experiments  upon  the  cadaver  indicate,  but  that 
it  is  melancholy  to  limit  one's  self  to  conjectures  when  the  specimen 
itself  can  be  examined.  Cooper^  gives  also  a  drawing  of  a  specimen 
of  an  old  dislocation  in  which  the  conoid  ligament  had  become  ossified. 

^  Polaillon :  Diet.  Eucyclopedique  des  Sciences  Medicales,  art.  Clavicule,  p.  719. 

2  Hamilton :  Fractures  and  Dislocations,  1880,  p.  626. 

■'  ^Malgaigne :  Loc.  cit.,  p.  432. 

*  Bolton  :  Annals  of  Surgery,  October,  1902,  p.  586. 

^  Cooper:  Dislocations  and  Fractures,  Am.  ed.,  p.  313.  *  Cooper:  Loc.  cit.,  p.  312. 


DISLOCATIONS  OF  THE  CLAVICLE.  6I3 

Experiments  upon  the  cadaver  liave  yielded  results  that  are  not 
entirely  in  accord  with  one  anotb.er,  Malgaiijne  found  that  even  in 
incomplete  dislocation  the  capsular  ligaments  were  completely,  and  the 
coraco-clavicular  partly,  ruptured.  Bouisson  and  Ader  found  that 
incomplete  dislocation  could  be  easily  produced  after  division  of  the 
acromial  ligaments  and  without  injury  to  the  coracoidal,  and  even  to 
such  a  degree  that  the  articular  surfaces  were  completely  separated 
vertically  from  each  other.  Ader  further  showed  that  after  division 
of  the  coracoidal  ligaments  a  complete  dislocation  could  be  readily 
produced  and  the  end  of  the  clavicle  removed  to  a  distance  of  two 
centimetres  from  the  acromion. 

Instead  of  rupture  of  the  upper  acromial  ligament  avulsion  of  the 
edge  of  bone  on  either  side  to  which  it  is  attached  has  frequently  been 
observed  clinically. 

Among  the  recorded  complications  are  simultaneous  dislocation  of 
the  sternal  end  of  the  same  or  of  the  other  clavicle,  fracture  of  the 
clavicle,  of  a  rib,  of  the  acromion  process,  of  the  coracoid  process,  of 
the  body  of  the  scapula,  and  subcoracoid  dislocation  of  the  shoulder 
of  the  same  side. 

Symptoms.  In  incomplete  dislocation  the  deformity  consists  in  the 
elevation  of  the  end  of  the  clavicle  to  a  variable  distance,  not  equal, 
however,  to  the  thickness  of  the  bone,  above  the  level  of  the  acro- 
mion, and  this  elevation  can  be  readily  recognized  by  palpation,  and 
can  generally  be  reduced  by  moderate  pressure. 

In  complete  dislocation  the  elevation  is  greater,  more  than  an  inch 
in  some  cases,  or  is  combined  with  displacement  outward,  backward, 
or  forward.  The  displacement  outward  is,  of  course,  due  to  the 
approximation  of  the  acromion  to  the  chest.  The  greatest  recorded 
overriding  is  one  inch  (Malgaigne,  Klar  ^).  It  has  been  observed  also 
in  some  cases  that  the  scapula  has  undergone  a  movement  of  rotation 
by  which  its  inferior  angle  is  carried  backward  toward  the  spine,  and 
the  anterior,  upper  angle  is  lowered,  a  movement  that  is  attributed  to 
the  action  of  the  weight  of  the  arm ;  it  has  been  observed  only  when 
the  displacement  inward  of  the  scapula  toward  the  chest  has  not  been 
very  marked. 

There  is  local  ])ain,  more  or  less  severe,  persisting  for  a  variable 
length  of  time,  and  increased  by  pressure  or  by  voluntary  movements 
of  the  shoulder  or  arm.  The  interference  with  voluntary  movements 
of  the  limb  varies  greatly,  and  corresponds  measurably  with  the  pain 
and  the  extent  of  the  displacement ;  some  patients  are  completely  dis- 
abled, others  can  use  the  limb  quite  freely. 

Diagnosis.  The  diagnosis  is  to  be  made  by  recognition  of  the 
changed  relations  of  the  bones,  which  is  easy  in  the  cases  of  complete 
dislocation,  and  seldom  difficult  in  the  incomplete.  In  the  latter  case 
the  local  pain  and  the  possibility  of  reducing  the  bony  prominence  by 
pressure,  together  with  its  immediate  reappearance  on  the  removal  of 
the  pressure,  will  give  the  clew.  The  (jucstion  will  then  lie  between 
dislocation  and  fracture  of  the  clavicle  near  its  end,  and  this  may  be 
answered  l)y  tracing  the  outline  of  the  acromion,  comparative  meas- 
urements of  the  two  clavicles,  and  consideration  of  the  presence  or 

'  Klar  :  Deutsche  Zcitsclirift  fiir  Cliir.,  vol,  Ixxiii.  p.  282. 


614 


DISLOCATIONS. 


absence  of  signs  peculiar  to  fracture.  The  error  of  mistaking  the 
injury  for  a  dislocation  of  the  shoulder  appears  to  have  been  quite 
frequently  made,  although  it  is  difficult  to  understand  how  it  could 
occur  if  the  examination  were  thorough. 

A  contusion  or  sprain  of  a  joint  in  which  the  end  of  the  clavicle 
stood  abnormally  high  might  easily  be  mistaken  for  a  recent  disloca- 
tion, since  it  would  present  all  the  signs  of  one,  but  the  error  would 
be  of  slight  importance  and  would  cause  no  harm  to  the  patient 
beyond  perhaps  a  needlessly  prolonged  confinement  of  the  lim.b. 

Prognosis.  The  prognosis  in  the  incomplete  form  is  good,  for 
although  the  displacement  has  commonly  persisted  in  some  measure, 


Fig.  383. 


Complete  supra-acromial  dislocation  of  the  clavicle. 

the  resulting  deformity  is  slight.  In  the  complete  form,  with  marked  dis- 
placement, there  is,  in  addition  to  the  common  imperfect  maintenance 
of  the  reduction,  an  occasional  inability  even  to  make  reduction.  In 
such  cases  the  functions  of  the  limb  may  or  may  not  be  seriously  inter- 
fered with  by  the  persistence  of  the  displacement.  In  the  unique  case 
quoted  above  from  Hamilton,  of  dislocation  by  direct  violence  acting 
upon  the  clavicle  from  below  upward,  the  bone  remained  displaced  two 
inches  upward,  yet  the  patient  could  use  the  arm  as  freely  and  strongly 
as  the  otlier.  On  the  other  hand,  in  one  of  Bardenheuer's  cases,  in  which 
the  displacement  persisted,  the  diminution  of  function  was  considerable, 
and  the  power  of  abduction  of  the  arm  was  almost  entirely  lost. 


DISLOCATIONS  OF  THE  CLAVICLE.  615 

Treatment.  In  most  cases  the  reduction  of  even  the  comj)lete  dislo- 
cation can  be  readily  eflPected  by  drawing  the  shoulder  either  directly 
upward,  or  upward  and  outward,  or  backward,  and  at  the  same  time 
pressing  the  clavicle  directly  toward  its  place.     The  only  opposition 

Fig.  384. 


> 

^ -. tJmm. i_ 

v.. 

Old  dislocation  of  the  outer  end  of  the  clavicle. 

that  ordinarily  needs  to  be  overcome  is  the  weight  of  the  arm,  which 
draws  the  shoulder  downward  and  inward  away  from  the  clavicle  ;  with 
this  is  sometimes  a.s.sociated  reflex  contraction  of  the  trapezius  which 
draws  the  clavicle  upward,  and  in  a  few  cases  the  end  of  the  clavicle 
has  passed  through  the  trapezius  in  such  a  way  that  the  interposed 
fibres  of  the  muscle  have  constituted  a  serious  obstacle  to  reduction. 
To  overcome  this  latter  obstacle  Moutet  ^  subcutaneously  divided  the 
clavicular  portion  of  the  trapezius  close  to  its  insertion  and  was 
then  able  easily  to  restore  the  bone  to  its  place  and  keej)  it  there  by 
a  bandage. 

In  making  reduction  the  arm  should  be  kept  near  the  side  and 
pressed  directly  upward.  If  the  shoulder  needs  to  be  drawn  directly 
outward,  this  should  be  done  by  the  hand  introduced  into  the  axilla, 
or  by  grasping  the  upper  part  of  the  arm  with  both  hands,  the  fingers 
resting  in  the  axilla,  and  the  thumbs  against  the  projecting  articular 
surface  of  the  clavicle,  and  thus  drawing  the  shoulder  outward  while 
pressing  the  clavicle  inward.  In  short,  reduction  is  to  be  eilcctcd  l)y 
forcing  the  acromion  upward,  and  outward,  forward,  or  backward,  as 
may  be  indicated   by  the  direction  of  the   displacement,  by  pressure 

1  Moutet:  Montpellier  Medical,  1861,  vol.  vi.  [i.  21S»,  (iiiulcd  hy  I'.ilaillou. 

43 


616 


DISLOCATIONS. 


exerted  upon  it  through  the  humerus,  and  by  pressing  the  end  of  the 
clavicle  in  the  opposite  direction. 

The  maintenance  of  the  reduction  "was  long  deemed  difficult.  The 
weight  of  the  arm  constantly  tends  to  reproduce  the  deformity,  to  carry 
the  shoulder  downward  away  from  the  clavicle,  and  the  dressings  era- 
ployed  did  not  satisfactorily  oppose  it.     The  following  simple  dressing 

which    I    devised    about    1883 
^®-  385.  has    proved    perfectly    satisfac- 

tory :  A  strip  of  stout  adhesive 
plaster,  about  four  feet  long  and 
two  or  three  inches  wide,  is 
placed  with  its  centre  under  the 
elbow,  the  forearm  being  flexed 
at  or  within  a  right  angle,  and  its 
two  ends  are  carried  upward, 
one  behind,  the  other  in  front, 
of  the  arm,  and  crossed  over  the 
shoulder  at  a  point  correspond- 
ing to  the  end  of  the  clavicle, 
and  then  fastened  to  the  front 
and  back  of  the  chest  respec- 
tively. While  applying  it,  the 
surgeon  must  press  the  elbow 
firmly  upward  and  the  clavicle 
downward.  The  eye  or  finger 
can  readily  detect  through  the 
plaster  any  recurrence  of  the  dis- 
placement. The  dressing  should 
be  worn  for  three  or  four  weeks. 
"Wiring  of  the  clavicle  to  the 
acromion  has  been  practised  a 
few  times  in  recent  and  in  old 
dislocations,  but  is  not  generally 
approved ;  if  anything  of  the 
kind  should  need  to  be  done 
periosteal  catgut  sutures  would 
probably  be  sufficient.  Delbet 
and  Mouquet^  report  a  good  result  obtained  by  two  silk  ligatures  attached 
to  the  coracoid  and  crossing  the  clavicle,  one  directly  above  the  coracoid, 
the  other  near  its  acromial  end. 


Dressing  for  supra-acromial  dislocation  of  the 
clavicle. 


Subacromial  Dislocation.     (Luxatio  Claviculae  Subacromialis.) 

This  dislocation,  of  wliich  Petit  was  the  first  to  make  mention,  is  so 
rare  that  Polaillon,  in  1875,  could  collect  only  six  recorded  cases;  the 
list  has  now  been  increased  to  eleven,  or,  adding  Newman's,  to  twelve. 
The  first  four,  quoted  by  Malgaigne,^  are  those  of  Melle,  1765,  Fleury, 
1816,  Tournel,  1837,  and  Baraduc,  1842.    The  others  are  two  observed 

1  Delbet  and  Mouquct :  Bull.  Soc.  de  Cliir.,  vol.  xxxv.  p.  558. 

2  .MalKai^ne  :  Log.  cit.,  pp.  448  and  452.  Malgaigne  thinks  Baraduc's  case  was  probably 
pathological,  not  traumatic.  The  reference  he  gives  for  Tournel  is  incorrect;  it  should 
be  1837,  not  1847. 


DISLOCATIONS  OF  THE  CLAVICLE.  617 

and  reported  by  Morel-Lavallee/  one  by  Dr.  W.  B.  Chase,^  one  by 
Dr.  J.  X.  Allen  ^  and  one  by  Dr.  Eaton.^  Konig'^  refei-s  to  one  tliat 
was  observed  in  Bruns's  clinic,  and  Bardenhener*'  makes  several  quo- 
tations from  the  report  of  a  case  by  Uhde,  but  does  not  give  the  refer- 
ence. He  speaks  also  of  a  case  reported  by  Gosselin  in  1881,  but  I 
have  been  able  to  find  only  a  clinical  lecture  by  Gosselin  on  a  case  of 
supra-acromial  dislocation.  To  these  may  be  added  Newman's  case  of 
sinudtaneous  dislocation  of  both  ends  of  the  clavicle  {vide  infra),  in 
which  the  outer  end  was  displaced  under  the  acromion. 

The  cause  in  these  cases  was  direct  violence  exerted  upon  the  upper 
surface  of  the  outer  end  of  the  clavicle  (Melle,  Tournel,  Chase),  a  fall 
upon  the  shoulder  in  three  (Fleury,  Morel-Lavallee's  two),  and  mus- 
cular eifort  in  one  (Allen). 

Allen's  patient,  a  stout  muscular  girl  sixteen  or  seventeen  years  old, 
was  chopping  wood,  and  at  the  moment  she  had  the  axe  raised  and 
was  about  to  deliver  the  blow  she  felt  a  sharp  pain  in  the  shoulder,  and 
the  arm  fell  powerless  by  her  side.  When  seen  six  weeks  later  there 
was  a  marked  depression  on  the  top  of  the  shoulder,  much  discoloration 
in  the  axilla,  and  the  inferior  angle  of  the  scapula  was  thrown  promi- 
nently outward.  There  was  complete  loss  of  voluntary  motion  of  the 
arm  and  hand,  and  numbness  of  the  entire  limb.  Reduction  was  easily 
effected  by  drawing  the  shoulder  outward  and  backward. 

Chase's  case  may  be  taken  as  a  type  of  direct  violence.  A  boy 
eight  years  old  fell  head  foremost  from  a  height  of  twelve  or  fifteen 
feet  and  struck  with  the  top  of  his  shoulder  against  the  rung  of  a 
ladder.  An  ecchy  mosis  over  the  outer  end  of  the  clavicle  showed  where 
the  blow  had  been  received.  The  acromial  end  of  the  clavicle  was  dis- 
located downward  and  somewhat  backward,  the  shoulder  was  flattened 
in  front,  and  the  acromion  very  prominent.  Reduction,  under  anaes- 
thesia, was  easily  effected  by  drawing  the  shoulder  outward  and 
backward  and  pressing .  the  clavicle  in  the  opposite  direction. 
There  was  no  tendency  to  recurrence  and  recovery  was  complete  in 
five  weeks. 

Of  the  other  two  cases  of  direct  violence,  in  one,  Tournel's,  the 
injury  was  caused  by  a  horse  stepping  upon  the  front  of  the  patient's 
shoulder  as  he  lay  on  the  ground  ;  in  the  other,  Melle's,  the  patient, 
who  was  a  Russian  soldier,  attributed  the  injury  to  an  effort  he  made 
when  six  years  old  to  lift,  with  the  aid  of  another  child,  a  keg  of  water 
l)y  means  of  a  stick  resting  on  his  shoulder.  He  had  also  a  dislocation 
of  the  corresponding  humerus,  which  apparently  had  been  received  at 
the  same  time. 

The  autopsy  in  Melle's  case  and  experiments  upon  the  cadaver  show 
that  the  lio-aments  unitino-the  acromion  and  coracoid  to  the  clavicle  are 
completely  ruptured;  the  clinical  facts  show  that  the  displacement  of 
the  clavicle  is  not  only  downward  and  outward  under  the  acromion  but 

1  Morel -Lavallee  :  Bull,  dc  la  Soc.  dc  Cliir.,  1863,  vol.  iv.  pp.  51  ami  '240. 

2  Chase :  Transactions  of  the  Medical  Society  of  the  State  of  New  York,  1879,  p.  170. 

3  Allen  :  New  York  Medical  Record,  IHSl,  vol.  xix.  p.  206. 
*  Eaton:  New  York  :M«dicnl  Record,  18H1,  v(d.  xx.  p.  734. 
^Kfinig:  Speciel.  Cliinirgie,  3d  ed.,  vol.  iii.  ji.  16. 

®  Bardeaheuer  :  Deutsche  Chir..  Lief.  ()3  a,  p.  89. 


618  DISLOCATIONS. 

also  backward  to  an  extent  that  leaves  the  acromial  facet  entirely  in 
front  of  the  clavicle.  This  is  perhaps  to  be  accounted  for  by  the  pres- 
ence of  the  head  of  the  humerus,  which  opposes  a  displacement  directly 
downward ;  and  the  same  anatomical  fact  may  explain  the  coincident 
dislocation  of  the  humerus  in  Melle's  case.  The  only  other  compli- 
cations observed  clinically  are  fracture  of  the  surgical  neck  of  the 
humerus,  in  one  of  Morel-Lavallee's  cases,  and  simultaneous  disloca- 
tion of  the  other  end  of  the  clavicle,  in  Newman's  ;  but  in  experiments 
upon  the  cadaver  fractures  of  the  acromion  and  of  the  clavicle  have 
been  met  with.  In  Melle's  case  the  meniscus  accompanied  the 
clavicle. 

Symptoms.  The  pain  at  the  moment  of  the  accident  may  be  severe 
or  slight ;  voluntary  movements  of  the  arm  are  interfered  with,  and 
sometimes  entirely  prevented ;  and  in  one  case  (Allen)  there  was  per- 
sistent numbness  and  tingling  in  the  arm  and  hand,  indicative  of  press- 
ure upon  the  brachial  plexus.  The  appearance  of  the  shoulder  is 
affected  by  the  sinking  of  the  acromion  and  rising  of  the  inferior  angle 
of  the  scapula  so  that  it  appears  to  be  inclined  forward.  The  shoulder 
is  usually  approximated  to  the  side  of  the  head,  but  may  be  on  a  lower 
level  than  the  opposite  one  because  of  the  inclination  of  the  trunk. 
The  central  portion  of  the  clavicle  may  be  depressed  below  the  level 
of  the  soft  parts  in  front  and  behind  ;  its  sternal  end  projects  sharply 
forward,  and  its  acromial  end  can  be  traced  with  the  finger  to  the  point 
where  it  engages  under  the  acromion  a  little  behind  the  articular  facet 
on  the  latter.  An  obscure  part  of  the  description  of  Tournel's  case, 
which  Malgaigne  found  unintelligible,  seems  to  mean  that  the  end 
of  the  clavicle  passed  entirely  under  the  acromion  and  projected  beyond 
its  outer  border.'  The  outline  of  the  acromion  and  its  empty  articular 
facet  can  usually  be  traced  with  the  finger,  although  in  one  case  the 
swelling  of  the  soft  parts  was  very  great. 

Prognosis.  The  prognosis  is  favorable ;  in  Tournel's  case,  in  which 
the  reduction  was  not  attempted,  the  patient  had  good  use  of  the  limb  ; 
in  Melle's  a  new  joint  had  formed  between  the  under  surface  of  the 
acromion  and  the  upper  surface  of  the  clavicle,  but  the  effect  upon  the 
functions  of  the  limb  cannot  be  known,  for  a  dislocation  of  the  humerus 
coexisted.  In  all  the  other  cases  in  which  the  record  is  sufficiently 
complete  reduction  was  easily  effected  with  or  without  the  aid  of  anaes- 
thesia, and  there  appears  to  have  been  no  tendency  to  recurrence  except 
in  one  case. 

Treatment.  Reduction  is  made  by  drawing  the  shoulder  outward 
and  backward,  the  arm  being  kept  parallel  to  the  trunk,  and  counter- 
extension  being  made  by  a  bandage  passed  around  the  chest,  Tournel 
reduced  by  placing  his  knee  between  the  shoulders  and  drawing  them 
forcibly  backward  ;  and  Uhde  did  likewise,  at  the  same  time  pressing 
the  clavicle  forward.  The  arm  should  be  fixed  against  the  trunk,  and 
the  forearm  supported  by  a  body  bandage  and  sling. 

1  Tlte  phrase  is :  "  L'epaule  presentait  en  outre  deux  saillies  ;  uiie  interne  et  superieure 
formee  par  I'acromion,  I'autre  externe  et  inferieure  formee  par  Textreniite  externe  de  la 
clavicule." 


DISLOCATIONS  OP  TBI:  CLAVICLE.  619 

Subcoracoid  Dislocation.      (Luxatio  Claviculse  Subcoracoidea.) 

Authority  for  the  belief  that  this  singular  displacement  has  ever  been 
clinically  observed  rests  upon  the  statements  of  two  surgeons,  Godemer 
and  Pinjon.  Godemer  met  with  his  first  case  in  I800  and  with  four 
others  in  the  following  five  years ;  Pinjon  reported  a  sixth  example  in 
1842.  Godemer's  cases  were  reported  to  the  Societe  medicale  d'  Indre 
et  Loire,  and  published  in  1843 ;  his  paper  was  republished  by  Mal- 
gaigne  in  the  Revue  medico-chirurgicale  de  Paris,  1847,  vol.  ii.  p.  155  ; 
Pinjon's  case  was  reported  in  the  Journal  de  Medeeine  de  Lyon,  1842, 
vol.  iii.  p.  58.  All  systematic  writers  upon  the  subject  are  agreed  in 
viewing  these  reports  with  much  suspicion  because  of  their  remarkable 
similarity  in  detail  and  the  great  anatomical  obstacles  to  the  production 
and  maintenance  of  the  displacement. 

The  features,  as  described  by  Malgaigne,  are  as  follows  :  Four  of  the 
six  patients  were  between  the  ages  of  sixty-seven  and  seventy-one 
years  ;  the  remaining  two  are  described  as  adults.  In  every  case  the 
injury  was  caused  by  a  fall  upon  the  shoulder. 

The  symptoms  were  :  1st.  More  or  less  pain  and  a  large  ecchymosis 
in  the  coraco-acromial  region. 

2d.  A  depression  at  the  normal  position  of  the  clavicle ;  this  bone 
was  found  to  be  inclined  downward  and  outward,  and  its  acromial  end 
lodged  in  the  axilla. 

3d.  The  coracoid  and  acromion  processes  were  prominent  under  the 
skin. 

4th.  The  shoulder  was  inclined  downward  and  forward  ;  the  inferior 
angle  and  posterior  border  of  the  scapula  formed  posteriorly  a  iH'ojection 
which  disappeared  when  the  shoulder  was  carried  upward  and  backward. 

5th.  The  arm  was  dependent,  but  could  be  easily  moved  in  any 
direction  except  upward  and  inward. 

Godemer  made  reduction  in  three  cases  by  grasping  the  clavicle  and 
disengaging  it  from  under  the  coracoid  process,  while  an  assistant 
forced  the  shoulder  backward  and  outward.  In  his  other  two  cases 
the  swelling  prevented  reduction  before  the  third  day.  Pinjon  failed 
to  reduce  because  of  the  fainting  of  his  assistant;  the  next  day  reduc- 
tion was  made  by  a  "  bone-setter." 

3.  SIMULTANEOUS  DISLOCATION  OF  BOTH  ENDS  OF  THE  CLAV- 
ICLE.    (TOTAL  DISLOCATION.) 

The  recorded  cases  of  this  injury  are  now  eleven  in  number :  Kiche- 
rand/  Morel-Lavallee,"  North;^  Hutchinson,^  Haynes,''  Col,^  Ijund,^ 
Kombeau,-  Hulke,''*  Newman,^"  and  Cousins. '^     Eight  of   the  patients 

'Richeraiid  :  Arch.  gen.  de  Med.,  1831,  vol.  xxv.  p.  108  ;  reported  by  Porral,  his  interne. 
2  Morel-Lavallee  :  Bull,  de  la  Soc.  de  Chir.,  1859,  vol.  ix.  p.  361. 
SxSTorth  :  New  York  Medical  Record,  18fi6,  vol.  i.  p.  79. 

*  Hutchinson  :  Lance^t,  1871,  vol.  ii.  p.  711. 
^Havnes:  British  Medical  .Journal,  1872,  vol.  i.  p.  99. 
6  Col':  Gaz.  dcs  Hopitaux,  1872,  p.  893. 

'Lund:  British  Medical  .Journal,  1874.  vol.  i.  p.  lOfi. 

*  Ronibeau  :  Bull.  Gen.  de  Therapeutique,  1874,  vol.  Ixxxvi.  p.  .'537,  reported  hy  Gros. 
'  Hulke  :   I^ancet,  185.5,  vol.  ii.  p.  245.  '"Newman:   Ibid.,  p.  524. 

'1  Cousins  :  Journ.  Am.  Med.  Assoc,  190(),  p.  19. 


620  DISLOCATIONS. 

were  males,  three  females  ;  their  ages  ranged  between  thirteen  and 
forty  years. 

Haynes's  patient,  a  weakly  girl,  thirteen  years  old,  produced  the 
dislocation  while  washing  the  back  of  her  neck  with  the  hand  of  the 
affected  side ;  there  was  a  complete  dislocation  forward  of  the  sternal 
end,  and  an  incomplete  dislocation  upward  of  the  acromial  end  of  the 
clavicle. 

In  all  the  other  cases  the  cause  was  external  violence,  usually  very 
great.  The  mode  of  production  is  varied,  the  most  common  form 
appearing  to  be  force  exerted  along  the  transverse  axis  of  the  shoul- 
ders, and  pressing  forward  the  one  that  suffers  the  injury. 

The  sternal  end  has  always  been  displaced  forward,  and  the  only 
additional  change  in  position  that  is  mentioned  is,  in  Morel-Lavallee's 
case,  that  it  had  moved  rather  upward  than  downward.  The  acromial 
end  was  displaced  backward  in  four  cases  (once  to  a  distance  of  three 
finger-breadths),  upward  and  outward  twice,  and  once  each  forward 
and  outward,  downward,  and  incompletely  upward.  In  Hutchinson's 
case  the  displacement  is  not  described  further  than  by  saying  that 
"when  pressure  was  made  on  either  end  of  the  dislocated  bone  the 
other  extremity  rose  perceptibly  and  protruded  the  skin." 

In  seven  of  the  cases  reduction  of  both  dislocations  was  effected  and 
maintained,  and  the  patients  recovered  with  good  use  of  the  limb  and 
but  little  deformity  ;  in  some  of  them  mention  is  made  of  more  or  less 
persistent  projection  of  the  sternal  end.  Morel-Lavallee  was  unable 
to  reduce  the  dislocation  of  the  outer  end,  although  he  made  direct 
traction  upon  it  with  a  hook  introduced  through  the  skin.  Lund,  with 
the  aid  of  chloroform,  could  only  bring  the  bone  "  into  fair  position  ;" 
at  the  end  of  ten  days  the  ends  were  found  "  fixed  in  their  new  posi- 
tion." In  Newman's  case,  dislocation  of  the  outer  end  under  the 
acromion,  reduction  was  impossible  ;  the  patient  withdrew  from  the 
hospital  on  the  tenth  day,  and  remained  disabled.  The  result  in 
Hutchinson's  case  is  not  recorded. 

Treatment.  Reduction  has  usually  been  effected  by  drawing  the 
shoulder  outward  and  backward,  and  recurrence  prevented  by  immo- 
bilizing it  in  a  suitable  position  by  means  similar  to  those  employed 
when  the  dislocation  involves  either  end  alone.  Hulke  used  a  gutta- 
percha splint  moulded  over  the  clavicle  and  bound  down  by  a  bandage 
that  crossed  the  shoulders  and  was  made  fast  in  front  and  behind  to 
another  about  the  waist.  Cousins  kept  each  end  in  place  by  a  sand- 
bag, the  patient  being  recumbent. 


CHAPTEE  XLIL 


Fig.  386. 


DISLOCATIONS  OF  THE  SHOULDER. 

Anatomy — Statistics — Classification — Anterior   Dislocations  :     Subcoracoid,   in- 

tracoracoid,  treatment. 

Anatomy. 

The  bony  surfaces  which  enter  directly  into  the  composition  of  the 
shoulder-joint  are  the  glenoid  cavity  of  the  scapula  and  the  postero- 
internal half  of  the  globular  head  of  the  humerus.  The  former  is  of 
irregularly  oval  shape,  the  more  pointed  end  above  and  the  broader 
one  below,  and  is  slightly  concave,  being  deepened  by  a  low  fibro-car- 
tilaginous  rim,  which  is  continuous  throughout  with  the  ca])sule,  and 
above  also  with  the  tendon  of  the  long  liead  of  the  biceps.  The  cavity 
looks  outward  and  forward  in  a  direction  nearly  midway  between  the 
sagittal  and  frontal  planes  of  the  body  when  the  scapula  occupies  its 
usual  position. 

Against  this  shallow  surface  the  head  of  the  humerus  rests,  being 
held  in  place  by  atmospheric  pressure,  the  tonicity  of  the  muscles,  and 
the  tension  of  thickened  portions  of  the 
capsule  in  different  positions  of  the  limb. 
On  the  outer  and  anterior  portion  of  the 
upper  end  of  the  humerus  is  the  greater 
tuberosity,  bounded  internally  in  front  by 
the  bicipital  groove  which  lodges  the  long 
tendon  of  the  biceps  and  has  upon  its  inner 
side  the  lesser  tuberosity.  Between  the 
upper  margins  of  these  tuberosities  and  the 
globular  articular  head  is  a  shallow  groove, 
the  anatomical  neck. 

The  acromion  and  coracoid  processes  lie 
above,  the  one  on  the  outer,  the  other  on 
the  inner  side,  and  the  strong  coraco-acro- 
mial  ligament  uniting  them  closes  in  the 
upper  part  of  the  joint,  but  is  separated 
from  its  cavity,  as  are  also  the  two  pro- 
cesses, by  the  interposed  capsule  and  the 
tendon  of  the  su])ras]>inatus. 

The  surface  of  the  head  of  the  humerus 
that   is  covered    by  articular   cartilage    is 
about  one-third  of  that  of  a  sphere,  and  the 
axis  passing  througli  its  centre  meets  the  long  axis  of  the  shaft  at  an 
angle  of  about  130  degrees.     The  linear  extent  of  the  glenoid  fossa, 

( G21  ) 


Acr. 


S '  F 

To  show  the  relations  of  the  hu- 
merus and  scajMila.  X,  the  lesser 
tuberosity.  /' and  .S  inilicntc  the 
frontal  and  sagittal  jilanes. 


622 


bISLOCATIOy& 


iucluding  its  fibro-cartilaginous  rinij  on  a  horizontal  section  is  less  than 
half  as  great  as  that  of  the  head  of  the  humerus ;  on  a  vertical  section 
it  is  about  two-thirds  as  great.  The  head  of  the  humerus,  therefore, 
simply  rests  against  the  fossa,  and  its  displacement  is  but  slightly 
opposed  by  the  conditions  of  contact  between  them.  The  muscles 
which  are  most  closely  associated  with  the  joint  are  the  suprasj^inatus, 
infraspinatus,  and  teres  minor,  attached  to  the  greater  tuberosity  in 
the  order  named  from  above  downward,  and  the  subscapularis,  which, 
arising  from  almost  the  whole  of  the  costal  surface  of  the  scapula, 
passes  forward,  broadly  covering  the  inner  side  of  the  joint  with  its 
fibres  and  tendon,  to  be  attached  to  the  lesser  tuberosity.  The  tendon 
of  the  long  head  of  the  biceps,  starting  from  the  upper  margin  of  the 
glenoid  cavity,  passes  upward  and  forward  over  the  head  of  the 
humerus  and  then  down  the  bicipital  groove,  carrying  with  it  a  pro- 
longation of  the  synovial  membrane  of  the  joint.  The  deltoid,  from 
its  broad  origin  on  the  spine  of  the  scapula,  the  acromion,  and  the 
clavicle,  covers  the  joint  superficially  on  its  posterior,  external,  and 
anterior  aspects ;  and  the  coraco-brachialis,  the  short  head  of  the 
bicepS;  and  the  great  vessels  and  nerves  lie  upon  its  inner  side. 

Fig.  387. 


Horizontal  section  ttirough  the  shoulder-joint :  A,  in  inward,  B,  in  outward  rotation.     (Hexle.) 

The  capsule  extends  from  the  free  margin  of  the  fibro-cartilaginous 
rim  of  the  glenoid  fossa,  or  from  the  surface  of  bone  immediately  out- 
side of  it,  to  the  anatomical  neck  of  the  htimerus.  At  the  upper  part 
its  scapular  insertion  is  at  the  base  of  the  coracoid  process  and  sepa- 
rated from  the  glenoid  fossa  by  the  tendon  of  the  biceps ;  on  the  pos- 
terior and  inner  portion  of  the  humerus  it  extends  somewhat  beyond 
the  cartilaginous  surface  along  the  projection  upon  which  the  head  rests. 
Between  the  two  tulierosities  the  synovial  membrane  by  ^vhich  it  is 
lined  is  prolonged  down  the  bicipital  groove,  and  is  reflected  over  the 
long  tendon  of  the  biceps.  The  capsule  is  reinforced  at  some  points 
by  thickenings  of  itself  which  are  known  as  ligaments  and  by  tendons 
of  the  scapular  muscles  ;  on  the  inner  side  it  is  perforated  by  the  tendon 
of  the  subscapularis,  and  there  shows  a  gap  through  which  the  cavity 
of  the  joint  communicates  with  the  subscapular  bursa,  a  large  pouch 
lying  against  the  inner  side  of  the  neck  of  the  scapula  and  the  root  of 
the  coracoid  process,  between  them  and  the  upper  part  of  the  subscap- 
idaris.  This  opening  lies  just  in  front  of  the  upper  part  of  the  ante- 
rior (inner)   margin  of   the  glenoid   fossa,  has  the  form  of  a  slit  or 


DISLOCATIONS  OF   THE  SHOULDER. 


623 


crescent,  and  is  usually  large  enough  to  admit  the  end  of  the  finger. 
When  the  syno\'ial  membrane  has  been  dissected  away  the  gap  has  the 
form  shown  in  Figs.  388  and  389,  and  is  partly  occupied  by  the  tendon 
of  the  subscapularis.       The  portion  of  the  capsule  which  forms  its 


Fig.  388. 


Supragleno-suprahiimeral, 
ligament 


Subscapularis 


The  shoulder-joiut  from  in  front.    (Farabe'jf.) 

upper  margin  is  called  the  gleno-humeral  ligament,  or,  to  adopt  the 
subdivisions  described  by  Farabeuf,^  the  supragleno-suprahumeral,  the 
portion  forming  the  lower  margin  is  the  supragleno-praehuraeral,  and 

Fig.  389. 


The  interior  of  the  shoulder-joint  from  behind:  1,  coraco-humeral  ligament;  2,  supragleno- 
suprahumeral  ligament ;  3  supragleno-prtehumoral  ligament ;  4,  prsegleno-subhumeral  liga- 
ment ;  5,  upper  edge  of  the  tendon  of  the  subscapularis  ;  .V,  its  lower  part ;  II,  biceps  tendon  ; 
C,  coracoid;  i?,  spine  of  scapula  ;  G,  glenoid  fossa.    (Farabeuf.) 

the  portion  immediately  below  the  latter  is  the  praegleno-subhumeral. 
These  different  portions  are  shown  in  Figs.  388  and  389,  which  are 
copied  from  Farabeuf's  paper.    Of  them  the  one  that  forms  the  lower 

1  Farabeuf:  Bull,  de  la  Soc.  de  C'hirurgie,  1885,  p.  391. 


624  DISLOCATIONS. 

margin  of  the  gap,  the  snpragleno-prsehumeral,  is  often  of  slight 
strength  and  underlies  and  is  intimately  adherent  to  the  tendon  of  the 
subsca])u]aris. 

The  coraco-humeral  ligament  is  a  strong  wide  band  extending  from 
the  root  and  outer  border  of  the  coracoid  process  over  the  top  of  the  joint 
to  the  neck  of  the  humerus  above  the  greater  tuberosity,  and  is  inti- 
mately connected  with  the  capsule  and  the  tendon  of  the  supraspinatus. 
It  is  thought  to  play  an  important  part  in  determining  the  position 
taken  by  the  limb  when  dislocated,  and  the  manceuvres  by  whicli  the 
dislocation  can  be  reduced. 

The  tendon  of  the  supraspinatus  passes  between  the  acromion  and 
the  head  of  the  humerus  and  is  attached  to  the  upper  part  of  the 
greater  tuberosity  ;  it  is  blended  with  the  capsule  and  is  separated  from 
the  acromion  by  a  bursa.  Below  it  come  the  tendons  of  the  infraspi- 
natus and  teres  minor,  passing  to  the  lower  and  middle  facets  respec- 
tively and  also  blended  with  the  capsule. 

Outside  the  capsule  is  a  loose  layer  of  connective  tissue  which  sepa- 
rates it  and  the  tendons  of  the  outer  muscles  from  the  inner  surface  of 
the  deltoid ;  within  this  layer  is  the  snbdeltoid  bursa,  extending  under 
the  acromion,  which  deserves  special  mention  because  of  the  fact  that 
when  the  tendon  of  the  supraspinatus  is  torn  away  from  its  attach- 
ment in  a  dislocation  and  retracts  under  the  acromion  with  the  adherent 
capsule,  this  bursa  is  thereby  opened  and  placed  in  communication  with 
the  cavity  of  the  joint,  and  the  upper  portion  of  the  capsule  is  thus 
greatly  lengthened.  The  influence  of  these  new  conditions  in  favoring 
recurrence  of  dislocation  has  been  discussed  in  Chapter  XXIX. 

AYith  respect  to  the  nerves  and  arteries  it  is  necessary  to  speak  only 
of  the  circumflex  nerve  and  of  the  arterial  branches  which  pass  out- 
ward, the  two  circumflex  and  the  subscapular.  The  circumflex  nerve 
winds  around  behind  the  neck  of  the  humerus  to  its  outer  side,  to  be 
distributed  to  the  deltoid  muscle  and  to  the  integument  covering  it. 
It  may  be  so  injured  in  a  dislocation  that  the  deltoid  will  be  paralyzed, 
perhaps  permanently. 

The  circumflex  and  subscapular  arteries  pass  outward  to  be  distrib- 
uted among  the  muscles  of  the  scapula  and  upper  part  of  the  arm  ; 
when  in  a  dislocation  the  head  of  the  humerus  presses  the  axillary 
artery  inward,  those  branches  are  put  upon  the  stretch  because  they  are 
prevented  by  the  attachment  of  their  branches  to  the  tissues  "from 
moving  inward  as  freely  as  the  main  trunk  does,  and  consequently  they 
may  be  ruptured  or  torn  away  from  the  side  of  the  main  artery.  This 
accident  may  be  the  consequence  of  the  dislocation  itself,  or  of  the 
efforts  to  reduce  it. 

The  movements  Avhich  are  most  frequently  concerned  in  the  produc- 
tion of  a  dislocation  are  outward  rotation  and  abduction.  In  the  latter 
the  elbow  is  raised  directly  outward  and  forward  from  the  side  of  the 
body  by  the  action  of  the  deltoid,  the  plane  in  which  it  moves  being 
more  or  less  exactly  that  which  would  be  represented  by  tlie  prolonga- 
tion of  the  broad  surface  of  the  shoulder-blade.  As  the  movement  is 
made,  the  head  slides  downward  on  the  glenoid  fossa,  the  long  head  of 
the  trice])s,  the  lower  part  of  the  subscapularis,  and  the  lower  and  inner 


DISLOCATIONS  OF  THE  SHOULDER.  G25 

portion  of  the  capsule  are  made  tense,  and  tlie  movement  is  arrested 
when  tiie  top  of  tlie  greater  tuberosity  comes  into  contact  with  the 
upper  margin  of  the  glenoid  fossa,  and  the  side  of  the  shaft  close  below 
the  tuberosity  touches  the  acromion.  If  the  movement  is  now  con- 
tinued, and  tlie  arm  raised  to  the  side  of  the  head,  it  is  effected  by  the 
rotation  of  the  scapula  and  the  elevation  of  its  outer  portion.  If,  on 
the  other  hand,  the  movement  is  continued  while  the  scapula  is  kept 
stationary,  the  centre  of  motion  is  transferred  to  the  point  of  contact 
between  the  humerus  and  the  edge  of  the  acromion,  and  the  head  of 
the  bone  is  forced  downward  against  the  already  tense  capsule  and 
ru])tures  it  at  its  lower  and  inner  portion,  where  it  presses  directly 
against  it. 

In  outward  rotation  when  the  arm  is  hanging  by  the  side  or  is  but 
slightly  abducted  the  movement  is  arrested  by  the  tension  of  the  cap- 
sule on  the  inner  side,  and  at  the  same  time  the  lower  and  outer  part 
of  the  greater  tuberosity  comes  into  contact  with  the  outer  lip  of  the 
glenoid  fossa  ;  if  the  movement  is  then  continued  the  capsule  yields, 
but  the  head  does  not  become  dislocated  unless  some  other  force 
intervenes  to  press  it  inward  through  the  rent  that  has  thus  been 
made. 

In  all  the  other  movements  similar  conditions  are  found,  and  dislo- 
cations following  them  are  less  frequent  only  because  the  movements 
are  themselves  less  frequently  carried  beyond  the  limits  set  by  the 
structure  of  the  joint.  Thus,  adduction  and  rotation  inward  are 
checked  by  contact  of  the  arm  with  the  body  before  the  capsule  is  ])ut 
upon  the  stretch,  and  extension  of  the  arm  behind  the  axillary  line 
must  be  carried  very  far  before  a  new  fulcrum  is  found,  and  is  also  a 
movement  that  is  rarely  produced  or  exaggerated  by  external  violence. 

Statistics. 

The  great  frequency  of  dislocation  of  the  shoulder  is  fully  ex]>lained 
by  the  structure  of  the  joint  and  by  its  exposure  to  the  dislocating 
action  of  direct  and  indirect  violence.  This  frequency  is  so  great 
that  dislocations  of  the  shoulder  are  about  as  numerous  as  all  the  other 
dislocations  of  the  body  combined.  The  tables  of  statistics  given  in 
Chapter  XXVII.  show  percentages  varying  from  40  to  51  of  all 
dislocations.  Malgaigne's  statistics  of  489  cases  contain  321  of  the 
humerus,  more  than  65  per  cent. ;  Gurlt's  collection  of  907  cases  in 
the  hospitals  of  Berlin,  Paris,  and  Philadelphia  contain  563  of  the 
shoulder,  58  percent.;  Bardenheuer^  saw  20  in  a  total  of  37  cases 
treated  in  one  year,  54  per  cent.  Kronlein's  statistics,  which  are  espe- 
cially valuable  because  they  are  made  u])  from  both  hospital  and  poly- 
clinic records,  give  a  total  of  207  dislocations  of  the  shoulder  out  of  400, 
51  per  cent,  of  which  184  were  in  males  and  only  23  in  females  ;  of  Mal- 
gaigne's 370  cases  97  were  in  women  ;  classified  according  to  age  and  sex 
they  both  show  that  the  injury  is  rare  in  youth,  infrequent  in  old  age, 
and  most  frequent  in  middle  life.  The  youngest  recorded  case,  excluding 
obstetrical  cases,  is  Villar's,^  fifteen  days  old.  The  relative  frecjuency  at 

^  Bardenheur:  Deutsche  Chirurgie,  Lief.  63  a,  p.  279. 
•^  Villar  :  Proviucial  Medical  Journal,  August  2(J,  1892 


526  DISLOCATIONS. 

the  different  ages,  established  by  taking  into  account  the  percentages 
of  total  population  belonging  to  those  ages,  differs  somewhat  from  the 
actual  frequency,  the  maximum  being  found  above  the  age  of  fifty 
years.  The  proportions  calculated  from  Kronlein's  statistics  with  the 
aid  of  the  relative  numbers  of  the  population  at  the  different  ages,  as 
given  in  Chapter  XXVII.,  are  five,  nine,  eleven,  and  twelve  respec- 
tively for  the  decades  from  thirty-one  to  seventy.  This  relatively 
greater  frequency  in  advanced  years  is  much  more  marked  in  women 
than  in  men,  a  fact  which  is  to  be  explained  by  the  greater  exposure 
to  violence  incident  to  the  occupations  and  habits  of  men  in  middle 
life.  It  indicates,  I  think,  that  a  much  larger  proportion  of  the  dislo- 
cations in  advanced  life  are  due  to  falls  while  walking  than  in  middle 
life,  since  that  is  an  accident  to  which  both  sexes  are  more  equally 
exposed  than  they  are  to  others. 

The  relations  pointed  out  by  Kronlein  as  existing  between  disloca- 
tions of  the  shoulder  and  those  of  the  elbow  and  fractures  of  the 
clavicle  are  interesting.  His  statistics  show  that  during  the  first  two 
decades  of  life,  a  period  in  which  dislocations  of  the  shoulder  are  rare, 
dislocations  of  the  elbow  and  fractures  of  the  clavicle  are  most  fre- 
quent. Thus,  of  109  dislocations  of  the  elbow  contained  in  his  table, 
80  of  the  patients  were  under  twenty  years  of  age,  and  of  100  cases  of 
fractures  of  the  clavicle  collected  by  him  70  of  the  patients  were  under 
ten  years  of  age  ;  while  of  207  dislocations  of  the  shoulder  none  of  the 
patients  was  less  than  ten,  and  only  2  less  than  twenty  years  old.  He 
thinks  fractures  of  the  clavicle  are  in  childhood  the  equivalent  injury 
of  dislocations  of  the  shoulder  by  direct  violence  in  middle  life,  and 
dislocations  of  the  elbow  the  equivalent  injury  of  dislocations  of  the 
shoulder  by  indirect  violence. 

Classification. 

The  head  of  the  humerus  in  leaving  the  joint  may  pass  at  first  up- 
ward or  downward,  backward  or  forward,  and  may  come  to  rest  in 
any  one  of  a  great  number  of  positions.  The  classification  of  the 
varieties  is  beset  with  much  difficulty,  because  of  their  number, 
because  of  the  frequency  and  importance  of  the  secondary  displace- 
ments, and  last,  though  not  least,  because  of  the  number  of  classifica- 
tions that  have  already  been  made  and  are  more  or  less  current.  The 
confusion  has  been  further  increased  by  the  application  of  the  same  or 
very  similar  terms  to  different  varieties  by  different  authors.  With 
the  rare  dislocations  backward,  and  the  still  rarer  ones  upward,  there 
is  no  difficulty  ;  the  uncertainty  arises  in  connection  with  those  in  which 
the  head  of  the  humerus  has  passed  across  the  anterior  lip  of  the  gle- 
noid fossa.  A  brief  account  of  some  of  the  classifications  and  terms 
heretofore  and  still  in  use  will  show  their  differences  and  resemblances, 
and  may  serve  as  a  convenient  introduction  and  preparation  for  the 
classification  that  must  follow. 

Sir  Astley  Cooper's  classification,  upon  which  those  now  in  use  in 
England  and  America  have  been  in  the  main  constructed,  recognized 
four  kinds  of  dislocations  :  1.  Downward  and  inward  into  the  axilla; 


DISLOCATIONS  OF  THE  SHOULDER.  627 

2.  Forward,  the  head  of  the  humerus  lying  under  the  clavicle  on  the 
sternal  side  of  the  coracoid  process  ;  3.  Backward ;  4.  Partial  inward, 
the  head  resting  against  the  outer  side  of  the  coracoid  process.  It  is 
apparent,  from  his  description,  that  the  first  and  fourth  included  the 
common,  frequent  cases,  those  which  are  now  generally  termed  "  sub- 
glenoid," or  '*  into  the  axilla,"  and  "  subcoracoid,"  respectively. 

A  few  years  later  Malgaigne  followed,  also  with  four  principal  forms, 
but  only  one  of  them  the  same  as  Cooper's.     His  grouping  is  as  follows  : 

!1.   Subcoracoid,  complete  ;  quite  common. 
2.   Subcoracoid,  incomplete  ;  rare. 
3.   Subglenoid ;  rare. 

TN-  1       ..        •  J  I  4.    Intracoracoid ;  most  common  of  all. 

Dislocations  inward     .     .     .   s  r     o  i    i      •     i 

I  5.    Subclavicular ;  rare. 

TN.  ,       ^-        II         1  f  6.    Subacromial;  rare. 

Dislocations  backward     ..-(.-     o   ■      • 

( /.   Subspinous;  very  rare. 

Dislocations  upward   ...      8.   Supracoracoid  ;  only  two  cases  known. 

All  these  titles  are  now  in  general  use ;  but  while  the  last  four,  and 
perhaps  the  second  also,  are  still  used  to  designate  the  forms  which  he 
designated  by  them,  the  others  have  been  used  with  diiferent,  some- 
times with  widely  different,  meanings.  The  first  form,  the  complete 
subcoracoid,  was  "  characterized  by  the  projection  of  the  head  of  the 
humerus  in  the  axilla,  and  its  position  exactly  below  the  coracoid  pro- 
cess ;"  it  would  be  included  in  Cooper's  first  group,  dislocation  down- 
ward into  the  axilla.  His  second  subdivision,  incomplete  subcoracoid, 
was  the  same  as  Cooper's  fourth,  partial  dislocation  inward.  His 
third,  subglenoid,  was  one  concerning  which  he  seems  to  have  been  far 
from  having  very  precise  notions ;  he  had  seen  only  one  case,  and  had 
been  able  to  collect  only  eleven  others,  and  of  these  the  symptoms 
differed  widely,  the  head  of  the  humerus  being  described  as  raising  the 
anterior  wall  of  the  axilla  in  one  case  and  the  posterior  in  another,  as 
resting  against  the  second  intercostal  space  in  one  and  against  the  third 
in  another,  and  even  as  having  perforated  the  wall  of  the  chest  and 
lodged  within  it.  The  one  feature  which  they  had  in  common,  and 
which  he  gives  as  pathognomonic,  was  that  the  head  of  the  humerus 
was  not  immediately  below  and  in  contact  with  the  beak  of  the  coracoid 
process,  but  was  separated  from  it  by  a  greater  or  less  interval.  Appar- 
ently the  class  was  created  simply  to  collect  together  the  odds  and  ends, 
the  irregular  cases  that  were  not  subcoracoid  ;  and  the  idea  which  sug- 
gested the  name  given  to  it  was  that  the  primary  displacement  took 
place  more  directly  downward  than  in  tlie  preceding  varieties.  It  will 
be  seen  that  the  name  has  since  been  applied  to  a  very  much  larger 
proportion  of  cases. 

His  second  main  division  embraced  two  varieties,  the  intracoracoid 
and  the  subclavicular.  Concerning  the  latter  there  is  no  misconcep- 
tion ;  the  term  has  remained  in  use,  and  with  the  same  meaning.  The 
group  is  made  uj)  of  those  cases  in  which  the  head  of  the  humerus  has 
passed  entirely  to  tlie  inner  side  of  the  coracoid  ])rocess,  and  lies  below 
the  clavicle.  But  the  other  term,  intracoracoid,  is  generally  employed 
in  a  much  more  restricted  sense  than  by  Malgaigne.     By  it  he  desig- 


(328  DISLOCATIONS. 

nated  the  greatest  number  of  dislocations,  more  than  two-thirds  of 
those  he  saw  at  the  Hopital  St.  Louis  ;  he  applied  it  to  those  in  ^vhioh 
the  head  of  the  humerus,  while  still  remaining  under  the  coracoid  pro- 
cess, overlapped  it  on  the  inner  side  by  more  than  half  its  own  diam- 
eter. Most  of  such  cases  are  now  termed  subcoracoid,  and  only  those 
in  which  the  head  has  passed  almost,  if  not  entirely,  to  the  inner  side 
of  the  process  are  called  intracoracoid. 

The  tendency  of  the  more  recent  French  and  German  writers  is  to 
make  a  single  group  of  all  the  dislocations  in  which  the  humerus  j)asses 
to  the  anterior  side  of  the  scapula,  containing  four  or  more  subdivisions 
or  varieties,  two  of  which,  the  subclavicular  and  intracoracoid,  in  the 
narrower  sense,  are  accepted  by  all  Of  the  remaining  two  principal 
ones,  the  subcoracoid  and  the  subglenoid,  the  former  is  made  to  include 
the  great  majority,  and  the  subglenoid  is  either  closely  and  distinctly 
restricted  to  the  very  rare  cases  in  which  the  head  of  the  humerus  is 
displaced  directly  downward  upon  the  tendon  of  the  long  head  of  the 
triceps,  or  Malgaigne's  grouping  is  accepted  with  all  its  diversities  and 
vagueness.  In  the  former  case  the  group  is  removed  from  the  prin- 
cipal division  of  "anterior"  or  " pr?eglenoidal "  dislocations,  and 
made  to  form  by  itself  another  principal  division,  termed  "  disloca- 
tions downward." 

The  English  and  American  writers,  as  a  rule,  divide  the  same 
cases  into  subglenoid  and  subcoracoid,  basing  the  distinction  between 
them  upon  the  clinical  feature  of  the  greater  or  less  facility  with 
which  the  head  of  the  humerus  can  be  felt  in  the  axilla;  those  in  which 
it  is  more  prominent  in  the  axilla  are  "  subglenoid,"  those  in  which 
it  is  more  prominent  behind  the  anterior  wall  of  the  axilla,  close 
beneath  the  coracoid  process,  are  "subcoracoid."  The  objections  to 
this  grouping  are  that  it  does  not  sufficiently  distinguish  between  pri- 
mary and  secondary  displacements,  and  that  the  clinical  features  upon 
which  it  rests  present  a  complete  series  of  intermediate  forms,  most  of 
which  might  be  as  properly  placed  in  one  group  as  in  the  other.  The 
arbitrariness  and  uncertainty  of  the  decision  are  well  shown  by  a  com- 
parison of  clinical  and  pathological  statistics.  Thus,  Hamilton  and 
Bryant  say  that  the  subglenoid  is  of  more  frequent  occurrence  than  the 
subcoracoid,  and  Erichsen  says  that  this  is  the  o])inion  of  most  English 
surgeons ;  while,  on  the  other  hand,  Flower,'  who  made  an  examina- 
tion of  all  the  specimens  contained  in  the  London  museums,  41  in 
number,  found  that  in  32  the  dislocation  was  subcoracoid,  and  he  adds, 
that  of  50  cases  recently  observed  by  him  in  living  patients  the  same 
was  true  of  "a  large  majority ;" ^  he  calls  attention  to  the  fact  that 
"  the  great  frequency  of  subcoracoid  dislocation  observed  in  this  series 
[of  specimens]  does  not  accord  with  the  descriptions  of  this  injury  gen- 
erally given  in  the  standard  surgical  works  of  the  country."  A  few 
years  later,  in  the  article  on  the  lujuries  of  the  Tapper  Extremity  which 
he  prepared  in  connection  with  ]\Ir.  Hulke  for  Holmes's  System  of 
tSarrjery,  Mr.  Flower  made  a  classification  in  which  the  influence  of 
this  important  investigation  is  apparent.     It  is  as  follows : 

'  Flower:  Transactions  London  Pathologir-al  Society,  1861,  vol.  xii.  p.  179. 
2  Tlie  ninnlier  is  <;iven  as  44  in   his  article  on  Injuries  of  the  Upper  Extremity  in 
Holmes's  System  of  Surgery. 


DISLOCATIONS  OF  THE  SHOULDER. 


629 


1,  SuBCOEACOiD.  Forward  and  slightly  downward.  On  to  the 
neck  of  the  scapula,  in  front  of  the  glenoid  fossa,  and  immediately 
below  the  coracoid  process.      Common. 

2.  Subglenoid.  Downward  and  forward.  Head  of  the  humerus 
in  front  of  the  inferior  costa  [border]  of  the  scapula,  below  the  glenoid 
fossa.     Rare. 

His  remaining  three  divisions  are  SubelaviGular,  SujDracoracoid,  and 
Subspinous,  the  latter  including  Malgaigne's  sixth  and  seventh. 

Turning  now  to  the  pathological  data,  to  the  recorded  results  of 
post-mortem  examinations  and  experiments  upon  the  cadaver,  and  con- 
fining our  attention  for  the  moment  to  the  forms  mainly  in  dispute, 
the  dislocations  forward  (or  inward)  and  downward,  and  to  the  points 
that  affect  the  position  of  the  head  of  the  humerus,  the  following  facts 
appear : 

The  head  of  the  humerus,  when  it  passes  across  the  anterior  edge  of 
the  glenoid  cavity,  must,  as  a  glance  at  Fig.  386  shows,  move  somewhat 
downward  so  as  to  get  below  the  beak  of  the  coracoid  process  ;  the  posi- 

FiG.  390. 

\C'oracoi(P 


Tendon 
of  triceps 

To  show  the  range  of  positions  that  may  be  taken  by  the  head  of  the  humerus  after  primary  dis- 
placement forward  or  downward  in  any  of  the  directions  between  the  arrows. 


tion  of  the  limb  that  most  favors  the  production  of  dislocation  is 
abduction  with  or  without  external  rotation.  The  inner  and  lower 
portion  of  the  capsule,  being  pressed  upon  by  the  head  of  the  humerus, 
tears  between  the  tendon  of  the  subscapularis  and  the  triceps,  the  rent 
being  small  or  large  and  varying  greatly  in  extent  and  direction  in  the 
different  cases,  but  it  is  always  on  the  anterior  and  inner  side,  and  the 
head  passes  more  or  less  completely  through  it.  If  the  movement  is 
more  directly  forward  and  inward  and  to  a  less  degree  downward,  as 
in  dislocations  by  direct  violence  received  on  the  outer  side  of  the 
shoulder,  the  head  of  the  bone  pusiies  the  subscaj)nlaris  muscle  before 
it  and  lodges  close  under  the  coracoid  process  and  between  that  nui.scle 
and  the  edge  of  the  glenoid  cavity.  In  this  case  no  secondary  dis- 
placement ensues,  and  the  form  would  be  classed  as  suhcordcold  by  all. 
If  the  movement  is  forcible  and  {)roIonged  the  subscapularis  may  be 


630  DISLOCATIONS. 

torn  entirely  across  and  the  head  may  pass  throngh  it  and  come  to  rest 
on  the  side  of  the  thorax  under  the  clavicle  ;  or,  as  in  a  case  quoted  by 
Malgaigne,  it  may  pass  over  the  upper  border  of  the  subscapularis  and 
come  to  rest  at  the  same  point.  If,  on  the  other  hand,  the  primary 
movement  downward  has  been  more  marked,  as  in  dislocations  effected 
by  hyper-abduction  of  the  arm,  the  head  either  passes  below  the  sub- 
scapularis or  tears  its  lower  portion,  and  then,  as  the  elbow  is  lowered 
the  head  rises,  pressing  the  subscapularis  or  its  untorn  portion  upward 
and  remaining  separated  by  it  from  the  coracoid  process.  The  extent 
and  direction  of  this  movement  of  the  head  are  determined  largely  by 
the  resistance  of  the  untorn  portions  of  the  capsule,  notably  the  outer 
and  anterior  part,  which,  by  preventing  the  further  descent  of  that 
part  of  the  humerus  to  which  they  are  attached,  compel  the  head  to 
move  upward  as  the  elbow  descends.  Other  factors  are  found  in  the 
muscles ;  if  the  head  lies  under  an  untorn  subscapularis  its  distance 
below  the  coracoid  process  will  be  greater  than  when  it  lies  under  only 
the  upper  portion  of  the  muscle,  and  if  in  addition  it  has  passed  under 
the  teres  major  or  downward  as  far  as  the  lower  border  of  the  peetora- 
lis  major  the  arm  will  remain  widely  abducted  or  even  with  the  elbow 
above  the  head  (luxatio  erecta).  Or,  departing  still  further  from 
what  is  usual,  it  may  perhaps  even  turn  backward  after  it  has  left  its 
socket  and  pass  under  the  long  head  of  the  triceps  to  lodge  behind  the 
glenoid  cavity,  the  alleged  subtricipital  dislocation. 

The  head  of  the  humerus  rests  against  the  inner  side  of  the  head  or 
neck  of  the  scapula  at  any  point  between  its  junction  with  the  broad 
axillary  border,  or  inferior  costa,  and  the  middle  of  the  anterior  lip 
of  the  glenoid  fossa,  and  it  may  lie  either  directly  against  the  edge  of 
this  lip  or  further  back  on  the  side,  as  is  clearly  shown  by  the  speci- 
mens of  old,  unreduced  dislocations  preserved  in  the  museums.  And 
according  as  it  occupies  one  or  the  other  position  it  will  be  more  or 
less  prominent  in  the  axilla  or  more  or  less  clearly  seen  and  felt  behind 
the  pectoralis  major  beneath  the  coracoid  process. 

It  is  evident,  then,  that  the  position  in  which  the  head  of  the  bone 
is  found  bears  only  a  limited  relation  to  the  point  at  which  it  left  the 
joint,  and  that  a  classification  which  is  sharply  made  upon  this  posi- 
tion is  not  only  arbitrary  and  uncertain  for  a  large  number  of  cases, 
but  also  favors  inattention  to  points  that  have  an  important  bearing 
upon  a  safe  and  easy  reduction. 

It  is  desirable  that  a  classification  should  not  deal  minutely  with 
unimportant  variations,  and  that  instead  of  multiplying  divisions  it 
should  rather  gather  into  a  few  groups  those  varieties  that  have  char- 
acteristic and  important  features  in  common ;  and  yet,  as  some  forms 
diifer  widely  in  their  symptoms  from  others  with  wdiich  they  are  on 
other  grounds  closely  related,  it  is  ecpially  desirable  to  recognize  and 
note  such  differences.  The  distinction  between  "  regular"  and  "  irreg- 
ular "  dislocations  made  by  Bigelow  at  the  hip  can  also  be  made  at 
the  shoulder,  taking  for  the  dislocations  downw^ard  and  forw^ard  the 
integrity  or  the  rupture  of  the  antero-external  portions  of  the  capsule 
as  the  determining  feature.  The  following  classification  is,  in  the 
main,  the  same   as  that  of  Mr.  Flower,  above  given,  and   the  later 


ANTERIOR  DISLOCATIONS   OF  THE  SHOULDER.  631 

French  and  German  writers.  It  differs  from  that  of  the  majority  of 
the  English  and  American  writers  in  restricting  the  gronp  of  the 
"  subglenoid  "  and  correspondingly  enlarging  that  of  the  ''  subcoracoid  " 
dislocations. 

(Subcoracoid ;  very  common. 
Intracoracoid ;  exceptional, 
subclavicular. 
(Subglenoid  ;  uncommon, 
erecta ;  very  rare, 
subtricipital  (?) 

13    ,     •  f  Subacromial ;  rare. 

Posterior "^  c  u     • 

(,  subspinous  ;  very  rare. 

Upward Supraglenoid  ;  very  rare. 

The  names  of  the  four  principal  divisions  indicate  the  direction  of 
the  primary  displacement ;  those  of  the  subdivisions  the  position  in 
which  the  head  of  the  bone  lodges,  with  the  exception  of  the  erecta, 
which  takes  its  name  from  the  attitude  of  the  limb,  and  the  subtricip- 
ital, which  rather  indicates  the  route  traversed  by  the  head  than  the 
position  finally  taken  by  it.  Between  the  anterior  and  the  downward 
the  divison  cannot  be  sharply  made,  and  in  many  of  the  cases  included 
among  the  first  the  primary  displacement  has  more  of  the  downward 
than  of  the  anterior  feature,  but  it  is  believed  that  by  enlarging  the 
subcoracoid  class  so  that  it  will  include  all  but  the  lowest  of  the  lower 
forms,  by  extending  its  range  so  that  it  will  distinctly  include  the 
lower  as  well  as  the  higher  primary  displacements,  the  necessity  of 
abducting  the  arm  to  eifect  reduction  in  those  cases  in  which  the  sec- 
ondary displacement  upward  is  marked  and  might  otherwise  lead  into 
error  will  be  less  liable  to  be  overlooked.  The  difficulty  of  distin- 
guishing between  the  subglenoid  and  the  lowest  of  the  subcoracoid 
will  arise  in  only  a  very  limited  number  of  cases  and  will  be  without 
practical  importance;  at  the  most  it  will  be  merely  a  question  of 
nomenclature. 

There  would  be  some  advantage  in  further  dividing  the  subcoracoid 
group  into  high  and  loiv. 

ANTERIOR  (AND  DOWNWARD)  DISLOCATIONS. 

1.  Subcoracoid. 

2.  Intracoracoid,  subclavicular. 

In  these  dislocations  the  head  of  the  humerus  passes  across  the 
anterior  lip  of  the  glenoid  fossa,  taking  at  first  a  direction  that  is  for- 
ward and  inward  and  more  or  less  downward  ;  it  may  subsequently 
move  upward  or  further  inward.  The  class  includes  two  subdivisions, 
the  subcoracoid  and  the  intracoracoid,  of  which  the  latter  is  hero  made 
to  include  also  the  more  marked  dislocation  inward  known  as  the  sub- 
clavicular. 

The   class  embraces   the   subcorac^oid,   partial  and  complete,  of  all 

autliors,    most   of   the    subglenoid    of    most    English    and    American 

authors,  and  the  intracoracoid   and   subclavicular  of  all.     The  terms 

"axillary  dislocations"  and  "dislocations  into  the  axilla"  are  annlied 

44 


g32  DISLOCATIONS. 

by  some  to  cases  that  are  here  called  subcoracoidj  and  the  term  "  pec- 
toral "  to  the  intracoracoid. 

1.  Subcoracoid  Dislocations. 

In  this  form,  which  includes  a  large  majority  of  all  cases,  the  head 
of  the  humerus  lies  under  and  in  close  proximity  to  the  beak  of  the 
coracoid  process,  or  at  a  distance  below  it  that  may  equal  or  even 
exceed  a  tinger-breadth.  The  centre  of  the  head  may  be  either  directly 
below  the  beak  of  the  coracoid  process  or  on  its  outer  or  inner  side. 
If  more  than  three-fourths  of  the  transverse  diameter  has  passed  to 
the  inner  side  of  the  coracoid  the  dislocation  is  termed  intracoracoid. 
The  class,  therefore,  is  continuous  with  the  subglenoid  below  and  with 
the  intracoracoid  on  the  inner  side,  and  the  separation  from  them  is 
arbitrary  and  artificial,  but  is  justified  by  custom  and  convenience  in 
description. 

Malgaig'ne  showed,  as  early  as  1835,  that  in  some  cases  the  articular 
surface  of  the  head  of  the  humerus  rested  on  the  anterior  edge  of  the 
glenoid  fossa,  and  such  he  termed  "  incomplete."  From  time  to  time 
cases  have  been  reported  and  the  eifort  renewed  to  establish  the  classifi- 
cation.-^ I  have  seen  two  such  cases.  The  formation  of  a  separate  class 
composed  of  such  cases  seems  unnecessary  and  even  undesirable,  for  they 
diifer  from  the  comjjlete  ones  only  in  degree,  and  the  difference  is  slight 
and  without  practical  importance  except,  perhaps,  in  the  liability  to  an 
error  in  diagnosis  because  the  symptoms  are  not  so  marked  as  in  the 
typical  cases.  That  is,  the  head  is  not  so  far  removed  from  its  place ; 
it  is  displaced  forward  rather  than  forward  and  inward.  On  the  other 
hand,  pain  is  much  more  severe  and  persistent,  presumably  because  the 
ligaments  are  kept  upon  the  stretch  instead  of  being  torn. 

The  injury  may  be  produced  by  direct  or  indirect  violence,  a  blow 
upon  the  outer  and  upper  part  of  the  shoulder  or  hyperabduction  of 
the  arm,  or  by  muscular  action.  AVhen  produced  by  direct  violence 
the  displacement  is  usually  in  a  direction  that  is  only  sufficiently 
inclined  downward  to  enable  the  head  to  pass  below  the  coracoid  pro- 
cess ;  in  a  case  reported  by  Krdnlein  ^  and  in  one  of  mine  ^  the  blow 
was  received  from  above  upon  the  acromion  and  only  dislocated  the 
humerus  after  it  had  broken  that  process.  The  extent  of  the  displace- 
ment inward  is  affected  partly  by  the  force  of  the  blow  and  the  extent 
of  the  laceration  of  the  capsule,  and  partly  by  the  contraction  of  tlie 
muscles  that  adduct  the  limb. 

Dislocations  by  indirect  violence  are  the  most  common,  the  force 
acting  to  produce  hyperabduction  of  the  joint.^ 

Hvperabduction  acts  by  bringing  the  outer  side  of  the  upper  end  of 
the  humerus  into  contact  Avith  the  edge  of  the  acromion  and  thus  cre- 

1  The  latest  is  a  paper  by  Ross :  Surgery,  Gynec.  and  Obst.,  1900,  p.  168. 

2  Kronlein:  Deutsche  Chirurgie,  Lief.  26,  p.  14. 

3  For  details  see  previous  editions. 

••  Hyperabduction  of  the  joint  must  be  distinguished  from  that  of  the  limb.  The 
former  can  take  place  even  while  the  elbow  is  below  the  level  of  the  shoulder,  for  it 
is  determined  by  the  relations  between  the  humerus  and  the  scapula :  and  as  the 
scapula  is  freely  movable  the  position  of  the  limb  ( with  reference  to  the  bodj-j,  when 
the  limit  of  motion  in  the  joint  is  reached,  varies  with  that  of  the  scapula. 


ANTERIOR  DISLOCATIONS   OF  THE  SHOULDER. 


633 


atiug  a  new  centre  of  motion  for  the  continued  movement,  the  etiVct  of 
which  is  to  cause  the  head  of  the  humerus  to  descend  and  rupture  the 
capsule  in  its  inner  and  lower  portion.  After  this  rupture  has  taken 
place  and  the  upward  movement  of  the  elbow  has  ceased,  the  contrac- 
tion of  the  muscles,  the  deltoid,  pectoralis  major,  and  latissimus  dorsi, 
draws  the  head  of  the  humerus  inward  past  the  anterior  lip  of  the  gle- 
noid fossa,  and  then  when  the  elbow  is  lowered  the  head  rises  along  the 
inner  side  of  the  joint,  for  the  untorn  outer  and  anterior  portion  of  the 
capsule  is  made  tense  and,  by  thus  preventing  the  descent  of  the  portion 
of  the  bone  to  which  it  is  attached,  compels  the  movement  to  take  place 

Fig,  391. 


Subcoracoid  dislocation  on  a  cadaver :  showing  rupture  of  lower  part  of  the  subscapularis. 

(B.  Anger.) 

about  this  portion  as  a  centre.  As  the  first  new  centre  of  motion  at 
the  edge  of  the  acromion  determines,  in  connection  with  the  muscles, 
the  primary  displacement,  so  the  second  new  centre  on  the  humerus 
at  the  outer  and  anterior  attachment  of  the  capsule  determines  the 
secondary  displacement  and  the  final  position  of  the  head  of  the  bone 
and  the  attitude  of  the  limb. 

Muscular  action,  the  contraction  of  the  muscles  of  the  individual 
himself,  can  produce  a  dislocation  either  by  drawing  the  head  of  the 
bone  directly  out  of  its  socket,  or,  much  more  commonly,  by  creating 
conditions  of  leverage  and  momentum  similar  to  those  existing  in  the 
production  of  dislocations  l)y  indirect  violence.  Fn  many  of  the  re- 
ported cases  it  is  difficult  to  re(;ognize  the  mechanism  of  the  nijiiry. 
The  least  questi()nai)le  examples  of  dislocation  effected  by  the  direct 


634  DISLOCATIONS. 

traction  of  the  muscles  are  those  in  which  the  injury  has  occurred 
during  a  convulsion.  A  considerable  number  of  such  have  been 
reported ;  in  one  quoted  below  (Pollosson,  page  637)  the  limb  seems 
to  have  been  in  the  position  of  imcard  rotation  at  the  moment  of  dis- 
location. The  examples  of  the  other  kind  are  numerous  and  varied, 
and  the  explanation  is  usually  simple.  A  painter  raises  his  arm 
to  work  upon  a  ceiling,  an  artilleryman  to  throw  a  shot,  a  patient 
lying  in  bed  to  free  its  curtain  caught  under  the  pillow,  a  woman  to 
grasp  an  object  hanging  on  the  wall ;  in  such  cases  hyperabduction  of 
the  joint  seems  to  be  the  probable  cause.  In  others  hyperabduction 
can  only  be  invoked  on  the  supposition  that  the  contraction  of  the  del- 
toid has  lowered  the  acromion,  the  arm  being  fixed  in  a  position  below 
the  shoulder,  as  in  Bichat's  case  of  the  notary  who  dislocated  his 
shoulder  in  an  attempt  to  raise  a  heavy  book  from  the  floor,  or  in  Volk- 
mann's  of  a  woman  who  tried  to  lift  a  heavy  pot  from  a  shelf  at  the 
height  of  her  shoulder,  or  Malgaigne's  athlete  who  tried  suddenly  to 
lift  a  man  kneeling  in  front  of  him,  or  Duplay's  very  muscular  patient 
who  stumbled  while  descending  a  staircase  and  threw  out  his  arm  to 
save  himself  from  falling  but  touched  no  object  with  it. 

In  other  cases  the  influence  of  muscular  action  is  entirely  indirect. 
Thus,  Eickert^  tells  of  a  very  muscular  man  twenty -five  years  old  who 
received  a  subclavicular  dislocation  by  resting  his  hand  against  a  wall 
over  his  head  and  sneezing.  Bardenheuer  mentions  a  similar  case 
observed  by  Saponi.  In  such  a  case  the  mechanism  is  essentially  the 
same  as  in  that,  for  example,  in  which  a  man  supported  himself  with 
his  arms  outstretched  against  a  wagon  to  receive  a  sack  of  grain  which 
another  threw  down  upon  his  back  and  thereby  dislocated  both  shoul- 
ders. 

It  is  impossible  in  most  cases  to  determine  the  exact  position  and 
attitude  of  the  limb  at  the  moment  the  dislocation  occurs,  and  the  rela- 
tive parts  taken  by  abduction,  rotation,  muscular  action,  and  direct 
impulsion  in  its  production.  At  present  it  can  only  be  said  that  every 
one  of  the  four  has  proved  sufficient  by  itself,  and  that  they  have  been 
found  to  co-operate  in  varying  degrees. 

Pathology.  The  capsule  is  torn  at  its  inner  and  lower  portion  between 
the  tendon  of  the  subscapularis  and  the  triceps,  and  the  rent  extends 
usually  along  the  inner  and  lower  border  of  the  glenoid  fossa  for  half, 
sometimes  even  two-thirds,  of  the  entire  periphery.  In  other  cases 
the  rent  extends  outward  and  backward,  rather  than  upward,  and  near 
the  insertion  of  the  capsule  upon  the  humerus.  Exceptionally,  the 
rent  is  very  small,  or  may  even  be  entirely  lacking,  its  place  being 
sometimes  taken  by  the  stripping  np  of  the  continuous  periosteum 
from  the  inner  side  of  the  neck  of  the  scapula.  Eve  ^  reported  a  case 
of  subcoracoid  dislocation  in  which  the  capsule  was  untorn,  but  was 
separated  from  the  anterior  border  of  the  glenoid  fossa,  remaining  con- 
tinuous Avith  the  periosteum  wliich  was  stripped  up  from  the  costal 
surface  of  the  scapula.     On  the  posterior  surface  of  the  head  of  the 

1  Eickert :  Maryland  Medical  Journal.  1883-S4,  vol.  x.  p.  339. 

^  Eve  :  Transactions  Pathological  Society  of  London.  18S0,  vol.  Ixiii.  p.  317. 


ANTERIOR  DISLOCATIONS  OF   THE  SHOULDER.  635 

humerus  was  a  deep  vertical  indentation  made  by  impact  against  the 
anterior  margin  of  the  glenoid  fossa.  An  almost  identical  case  was 
shown  to  the  London  Pathological  Society  by  D'Arcy  Power.^  In 
ISSO  I  presented  to  the  Xew  York  Surgical  Society  the  shoulder-joint 
of  an  old  man  who  had  died  of  pneumonia  a  week  after  he  had  dis- 
located his  shoulder.  The  dislocation  was  well  marked,  and  reduction 
was  effected  with  the  aid  of  ether.  The  joint  was  opened  from  behind, 
and  the  capsule  was  found  untorn;  the  tendon  of  the  subscapularis  was 
partly  detached  at  its  insertion,  but  at  no  point  throughout  its  entire 
thickness,  and  the  upper  facet  of  the  greater  tuberosity  was  broken  off 
in  several  pieces,  but  not  widely  separated.  I  think  this  represents 
a  type:  dislocations  produced  by  a  blow  upon  the  outer  and  posterior 
aspect  of  the  shoulder  while  the  limb  is  in  inward  rotation.  This 
attitude  relaxes  the  inner  part  of  the  capsule  and  makes  tense  the 
muscles  attached  to  the  greater  tuberosity. 

The  subscapularis  muscle  is  sometimes  simply  pressed  inward  and 
separated  from  the  scapula  by  the  interposed  head  of  the  humerus,  but 
in  many  cases  it  is  torn  more  or  less  widely  from  its  lower  border 
upward,  and  its  upper  portion  may  lie  upon  the  head  of  the  humerus 
and  separate  it  from  the  coracoid  process.  Occasionally,  instead  of 
being  ruptured,  the  muscle  is  torn  away  from  its  attachment  to  the 
humerus,  perhaps  bringing  with  it  the  lesser  tuberosity.  I  have  seen 
one  case  in  which  the  head  passed  beneath  the  tendon  and  then  to  its 
inner  surface,  so  that  division  of  the  tendon  was  required  to  effect 
reduction. 

The  supraspinatus  is  sometimes,  probably  often,  torn  from  its  attach- 
ment to  the  humerus,  and  the  same  is  true  in  a  less  degree  of  the  infra- 
spinatus, and  occasionally  even  of  the  teres  minor. 

The  teres  major  is  sometimes  slightly 
torn,  apparently  by  the  partial  passage  of 
the  head  of  the  humerus  between  it  and 
the  subscapularis. 

The  anterior  edge  of  the  glenoid  fossa  is 
occasionally  broken  off,  and  detachment  of  a 
portion  of  its  fibro-cartilaginous  rim  seems 
not  infrequent ;  it  is  sometimes  pushed 
away  to  some  distance,  bringing  with  it  subcoracoid  dislocation :  to  show 
the  periosteum  of  the  scapula.     The  aero-    l^'  t'"'""''''  ^'hT  •^7°'"'!'?"  "' 

.    i  -  ,-  1   ,  111  the  humerus  indifferent  positions. 

mion  and  coracoid  process  have  both  been 

found  broken,  but  such  injury  appears  to  have  been  purely  incidental 

and  should  be  classed  as  a  complication. 

The  head  of  the  humerus  lies  against  the  edge  of  the  glenoid  fossa, 
or  fm^ther  l)ack  against  the  side  of  the  neck  of  the  scn]iula,  and  cither 
close  u])  against  the  beak  of  the  coracoid  process  behind  the  coraco- 
brachialis  and  the  short  head  of  the  biceps,  or  lower  down  at  a  distance 
determined  by  its  relations  to  the  subscapularis  and  by  the  tension  of 
the  untorn  portion  of  the  capsule.  It  may  lie  largely  on  the  outer  side 
of  the  coracoid  process,  or  immediately  below  it,  or  it  may  pass  entirely 

1  D'Arcy  Power:  Lancet,  November  24,    1888. 


636 


DISLOCATIONS. 


to  its  inner  side  (intracoracoid  dislocation),  and  it  may  be  in  outward 
or  inward  rotation  (Fig.  392)  or  in  any  intermediate  attitude. 

As  has  been  already  said,  avulsion  of  the  tuberosities  may  take  the 
place  of  laceration  of  the  muscles  attached  to  them;  this  has  been 
rarely  noted  of  the  lesser  tuberosity,  but  frequently  of  the  greater, 
and  especially  of  its  upper  and  middle  facets.  Yon  Thaden,^  who 
made  a  study  of  this  feature,  found  that  the  upper  and  middle  facets 
were  each  sometimes  torn  off  separately,  but  the  lower  one  only  in 
connection  with  the  other  two.  The  complication  is  of  importance 
because  of  the  consequent  loss  of  the  control  of  the  attached  muscles 
over  the  humerus  and  the  consequent  exposure  to  recurrence  of  the 
dislocation  (see  Chapter  XXIX),  and  because  it  opens  the  way  for 
the  escape  of  the  long  tendon  of  the  biceps  from  its  groove  and  its 
interposition  between  the  humerus  and  its  socket  in  such  a  way  as  to  con- 
stitute a  serious  obstacle  to  reduction.  In  the  specimens  Yon  Thaden 
examined  he  found  the  tendon  thus  interposed  three  times.     Korte^ 

Fig.  393. 


Subcoracoid  dislocation  of  the  left  shoulder. 

reported  a  similar  case  in  which  the  tendon  had  slipped  entirely  out 
of  its  groove  and  was  wound  around  the  outer  and  posterior  side  of 
the  head.  Graessner^  found  the  greater  tuberosity  broken  24  times  in 
48  dislocations,  but  apparently  in  many  of  them  the  fragment  was  only 
a  small  scale  of  bone,  practically  an  avulsion  of  the  tendon.  Delbet 
(loc.  cit.)  found  it  22  times  in  110  cases,  Bollinger  (loc.  cit.)  5  times 
in  39,  and  Goebel^  20  times  in  43. 


1  Von  Thaden:  Arch,  fiir  klin.  Chir.,  vol.  vi,  p.  67. 

2  Korte:  Ibid.,  vol.  xxvii,  p.  747. 

'  Graessner:  Veroff  aus  dem  Gebiete  des  Militar-Sanitats,  Hft.  .35,  p.  180. 
*  Goebel:  Ztlblatt.  fur  Chir.,  1909,  p.  1219. 


ANTERIOR  DISLOCATIONS  OF   THE  SHOULDER.  637 

When  the  tuberosity  or  a  portion  of  it  is  thus  broken  oft",  the  frag- 
ment hes  over  or  in  the  glenoid  fossa,  and  the  broken  surface  of  the 
humerus  rests  against  the  inner  surface  of  the  neck  of  the  scapula  or 
engages  the  edge  of  the  fossa.  The  upper  and  outer  portion  of  the 
capsule  thus  separated  from  the  humerus  may  remain  interposed  be- 
tween the  head  of  the  humerus  and  its  socket  and  prevent  reduction. 
After  reduction  of  the  dislocation  the  tuberosity  unites  with  the  humerus 
with  more  or  less  irregularity  and  deformity. 

Except  in  connection  with  fracture  of  one  or  the  other  tuberosity 
the  long  tendon  of  the  biceps  is  rarely  dislocated,  but  it  is  sometimes 
torn  away  from  its  insertion  or  ruptured. 

In  some  specimens  of  old  unreduced  dislocation  a  vertical  groove  has 
been  found  on  the  articular  surface  of  the  head  of  the  humerus  which 
was  thought  to  have  been  caused  by  prolonged  contact  with  the  edge 
of  the  glenoid  fossa.  Malgaigne,  who  took  a  special  interest  in  the 
specimens  as  supposed  examples  of  incomplete  dislocation,  suggested 
that  the  groove  might  have  been  caused  at  the  time  the  injury  was 
received  by  the  forcible  impact  of  one  bone  against  the  other.  It  is 
interesting  to  find  that  this  suggestion  has  been  confirmed  by  autopsy  in 
Eve's  and  Power's  cases  mentioned  above  and  by  two  specimens  of 
recent  dislocation  preserved  in  the  Museum  of  the  University  of  Edin- 
burgh and  reported  in  an  interesting  and  valuable  paper  by  Caird,^  and 
by  one  reported  by  Broca  and  Hartraann  ;-  the  indentation  lay  wholly 
or  in  part  along  the  junction  of  the  head  and  shaft  above  and  behind  the 
greater  tuberosity,  was  from  one  to  one  and  a  half  inches  long,  and 
from  one-quarter  to  one-half  an  inch  deep,  and  accurately  fitted  the 
inner  lip  of  the  glenoid  fossa.  The  suggestion  that  the  causation  of 
fracture  of  the  anatomical  neck  may  be  referred  to  the  same  mechanism 
seems  very  plausible.  Dolliuger^  attributes  it  to  forcible  outward 
rotation,  and  if  that  view  is  correct  it  might  easily  occur  in  a  fresh 
case  or  during  an  effort  to  reduce.  He  found  it  in  5  of  39  cases 
operated  upon.  Delbet^  found  it  22  times  in  110  reported  cases  of 
operative  reduction  or  autopsy.  A  similar  indentation  adjoining  the 
lesser  tuberosity  is  reported  by  Pollosson  ^  in  a  double  dislocation  by 
muscular  action — convulsions  of  eclampsia.  The  position  indicates 
that  the  limbs  were  in  inward  rotation  at  the  moment  of  dislo- 
cation. 

The  axillary  vessels  and  nerves  are  pressed  inward  and  are  some- 
times injured,  occasionally  with  partial  and  transient  paralysis. 

Symptoms  and  Diagnosis.  The  description  of  the  symptoms  will  be 
made  simpler  b}'  limiting  it  at  first  to  those  commonly  found  in  the 
medium  displacements,  and  subsequently  indicating  the  dift'erences  or 
modifications  peculiar  to  the  exceptional  grades  and  conditions. 

The  patient  sits  with  his  trunk  inclined  toward  the  injured  side,  and 
supports  the  forearm  with  the  other  hand.    The  shoulder  is  flattened 

'  Caird:  Edinburgh    Medical   Journal,    February,    1887. 
2  Brof-a  and  Hartmann:  Bull,  de  la  Soe.  Anat.,  1890,  No.  14. 
'  Dollingor:   Ergebnissc  der  C'liir.  und  Orthop.,  1911,  vol.  iii. 
"  Delbet:  Arch.  gen.  de  Med.,  1S9.3,  p.  19. 
^Pollosson:  Rev.  de  Chir.,  November,   1888,  p.  927. 


638  DISLOCATIONS. 

on  the  outer  side  so  that  the  Hne  of  the  deltoid  runs  straight  down 
from  the  acromion  and  makes  a  more  marked  angle  with  the  arm 
at  its  insertion  than  is  usual.  The  anterior  fold  of  the  axilla  lies 
lower,  farther  from  the  clavicle  than  its  fellow  of  the  opposite 
side,  and  its  creases  appear  deeper,  as  if  the  arm  were  applied  more 
closely  against  the  chest,  and  the  outer  part  of  the  subclavicular  fossa 
appears  fidl. 

The  elbow  stands  a  little  away  from  the  side  and  can  be  easily 
abducted,  but  any  attempt  to  bring  it  nearer  the  side  causes  pain  and 
is  resisted  ;  it  may  be  in  the  axillary  line,  or  in  front  of  or  behind  it. 
When  the  elbow  is  flexed  at  a  right  angle  the  forearm  is  directed  for- 
ward and  inward  ;  its  direction  can  be  passively  changed  to  either  side, 
but  not  freely.  The  hand  cannot  be  brought  to  the  opposite  shoulder. 
Voluntary  movements  of  the  dislocated  joint  are  declared  by  the 
patient  to  be  impossible,  and  pain  is  complained  of  in  the  shoulder, 
sometimes  extending  down  the  arm. 

If  the  axis  of  the  arm,  viewed  from  in  front,  is  prolonged  upward 

by  the  eye  it  will  be  seen  to  pass  to  the  inner  side  of  the  glenoid 

cavity,  and  if  the  fingers  are  firmly  pressed 

Fig.  394.  against  the  anterior  wall  of  the  axilla  in  the 

line  of  this  prolongation  and  a  little  below  the 

.^,_ f^c-~s,      coracoid  process  they  will  encounter  the  firm 

^  .,.;;;:::v:::::v-v."V-...|.-...^^i^  resistance  of  a  solid  body ;  palpation  shows 
this  body  to  be  globular,  and  if  it  can  be 
grasped  between  the  thumb  and  finger,  or  if 
the  finger  can  find  some  projection  on  its  sur- 
face, it  will  be  found  to  share  in  slight  move- 
ments of  rotation  connnunicated  to  the  arm  by 
the  other  hand  of  the  surgeon. 

If  now  the  head  of  the  humerus  is  sought 

Diagram  to  show  the  effect     ^^^  ^J  palpation  in  its  normal  position  it  will 

of  position  upon  the  apparent     not  be  found  there  ;  the  hngers  can  be  pressed 

length  of  the  arm  in  disioea-     j^  deeply  Under  the  acromiou  from  the  outer 

tionoftheshoulder.  ^  aero-        -^  j  ^^^         ^^         -^     ^f    ^^^    acromiou    is 

mion ;  B,  lower  end  of  hu-  '.  &  ,—,,.. 

menis.  prominent  and  can  be  easily  traced.      Ihis  is 

marked  when  the  limb  is  abducted. 

If  the  elbow  be  further  abducted  and  the  surgeon  pass  his  fingers 
well  up  into  the  axilla  he  can  there  feel  the  head  of  the  humerus  more 
or  less  distinctly  according  as  the  displacement  is  low  or  high. 

If  the  distance  be  measured  from  the  outer  margin  of  the  acromion 
to  the  external  epicondyle  of  the  humerus  or  the  olecranon,  it  will 
usually  be  found  somewhat  greater,  perhaps  half  an  inch,  on  the 
injured  than  on  the  uninjured  side,  but  if  successive  measurements 
are  taken  as  the  arms  are  abducted  the  difference  will  disappear,  and 
in  complete  abduction  «the  distance  will  be  greater  on  the  opposite  side. 
The  reason  for  this  is  seen  by  a  glance  at  Fig.  394. 

As  in  most  other  dislocations,  the  capital  point  in  the  diagnosis  is 
the  recognition  of  the  head  of  the  bone  and  the  determination  of  its 
relations  to  the  socket  from  which  it  has  escaped.  Ordinarily,  both 
of  these  can  be  accomplished  at  the  shoulder  with  ease  and  certainty, 


ANTERIOR  DISLOCATIONS  OF   THE  SHOULDER.  630 

and  the  examination  is  difficult  only  when  the  patient  is  very  fat  or 
the  parts  much  swollen. 

As  the  attitude  and  range  of  motion  of  the  limb  depend  mainly 
upon  the  tension  of  the  untorn  portion  of  the  capsule,  they  will  be 
modified  when  the  capsule  is  freely  torn.  It  is  in  such  cases  that  the 
diagnostic  sign  so  freely  trusted,  the  inability  to  bring  the  elbow  against 
the  chest  and  to  place  the  hand  on  the  opposite  shoulder,  is  lacking  or 
only  slightly  marked. 

When  the  displacement  of  the  humerus  is  less  than  usual,  when  its 
head  rests  upon  the  edge  of  the  fossa,  the  "  incomplete"  dislocation 
of  some  writers,  the  symptoms  are  modified  to  this  extent,  that  the 
flattening  of  the  shoulder  and  the  abduction  of  the  elbow  are  less — 
the  elbow  may  even  lie  close  to  the  body, — and  the  head  projects  more 
directly  in  front,  resting  on  the  anterior  edge  of  the  glenoid  fossa 
instead  of  dropping  over  to  its  inner  side  ;  but  the  limb  is  equally 
fixed  and  incapable  of  being  voluntarily  moved.  The  pain  also  is 
greater.  It  has  occasionally  happened  that  the  dislocation  has  been 
reduced  by  the  manipulations  used  to  make  the  diagnosis. 

Treatment.  The  treatment  will  be  described  in  connection  with  that 
of  the  following  variety. 

2.  Intracoracoid  Dislocations  (Subclavicular  Dislocations). 

To  avoid  misapprehension  I  repeat  that  the  term  "  intracoracoid  " 
was  applied  by  Malgaigne  to  the  class  of  cases  which  he  deemed  of 
most  frequent  occurrence,  comprising  two-thirds  of  the  forty-nine 
cases  of  shoulder  dislocation  observed  by  him  at  the  Hopital  St.  Louis, 
those  in  which  the  head  of  the  humerus  is  so  placed  that  from  one- 
third  to  two-thirds  or  three-fourths  of  its  transverse  diameter  lies  to 
the  inner  side  of  the  coracoid  process.  Most  of  such  cases  are  now 
habitually  spoken  of  as  "  subcoracoid,"  and  the  terms  intracoracoid 
and  subclavicular  are  restricted  to  those  cases  in  which  the  bone  is 
displaced  still  further  inward.  As  between  "intracoracoid"  and 
"subclavicular"  thus  employed,  I  prefer  the  former  name  because  it 
contains  that  of  the  anatomical  landmark  the  relations  to  which  form 
the  basis  of  the  classification. 

The  injury  may  be  produced  by  direct  violence  received  upon  the 
outer  aspect  of  the  shoulder  or  by  hyperabduction  of  the  arm.  The 
essential  causative  feature  of  the  variety,  as  compared  with  the  sub- 
coracoid, is  that  the  action  of  the  original  violence  is  ju'olonged,  or 
that  the  secondary  cause  exaggerates  the  secondary  disi)laccment 
upward  and  inward.  After  a  primary  displacement  forward  and  down- 
ward by  abduction  of  the  limb,  anything  that  forcibly  presses  or 
draws  the  arm  inward,  such  as  pressure  inward  against  the  elbow,  or 
the  contraction  of  the  deltoid  and  pectoralis  major,  may  effect  this  dis- 
placement if  the  head  of  the  bone  has  ])assed  under  the  subscapularis, 
or  if  this  muscle  has  been  sufficiently  torn.  The  head  of  the  humerus 
lies  against  the  wall  of  the  chest,  or  rather  against  the  serratus  niag- 
nus,  on  one  side,  and  against  the  costal  surlace  of  the  neck  of  the 
scapula  on  the  other.     The  subscapularis  usually  is  widely  torn  ;  in 


640 


'  DISLOCATIONS. 


McNamara's  case,  quoted  by  Malgaigne/  it  was  untorn,  and  the  head 
of  the  humerus  had  stripped  it  away  from  the  scapula  and  had  risen 
above  its  upper  border,  lying  against  the  root  of  the  coracoid  pro- 
No  muscle  or  tendon  was  torn.     In  one  of  my  own  the  head 


cess. 


of  the  bone  had  passed  beneath  and  entirely  to  the  inner  side  of  the 
subscapularis. 

The  capsule  is  extensively  torn,  and  the  greater  tuberosity  usually 
broken  off  in  whole  or  in  part  and  lying  in  the  glenoid  fossa. 

The  head  of  the  humerus  passes  behind  the  muscles  arising  from 
the  coracoid  process  (in  one  recorded  case,  Roser's,^  in  front  of  the 
coraco-brachialis  and  biceps  and  behind  the  pectoralis  minor)  and 
occasionally  is  partly  interposed  between  the  contiguous  borders  of  the 
deltoid  and  pectoralis  major,  being  then  subcutaneous.  It  may  lie 
immediately  under  or  a  little  behind  the  clavicle,  in  one  case  (Meyer) 

Fig.  395. 


Imracoracoid  dislocation. 

it  even  projected  above  and  behind  it,  and  it  has  usually  been  found 
rotated  inward. 

The  long  tendon  of  the  biceps  is  broken,  or  displaced  across  and 
beyond  the  fractured  surface  left  by  the  avulsion  of  the  greater 
tuberosity. 

1  Malgaigne:  Loc.  cit.,  p.  525.  .      ,     ,  ,     ^    ,  . 

■'  Roser:  Arch,  fiir  phys.  Heilkunde,  1844,  p.  582.  The  dislocation  had  lasted  for  seven 
years,  and  many  attempts  had  been  made  to  reduce  it. 


ANTERIOR  DISLOCATIONS  OF   THE  SHOULDER. 


641 


The  main  vessels  and  nerves  lie  rather  behind  the  head  than  between 
it  and  the  wall  of  the  chest. 

Symptoms.  The  attitude  of  the  patient  and  the  general  appearance 
of  the  shoulder  are  the  same  as  in  the  subcoracoid  variety  ;  the  details 
differ  mainly  in  degree,  some  being  less,  others  more,  marked.  The 
flattening  of  the  shoulder  is  greater,  as  is  also,  in  some  cases,  the  ful- 
ness of  the  subclavicular  fossa,  but  this  fulness  is  nearer  the  median 
line.  The  elbow  may  lie  near  the  side,  eVen  in  contact  with  it;  the 
axis  of  the  arm  prolonged  upward  in  front  passes  well  to  the  inner 
side  of  the  coracoid  process.  The  fingers  cannot  be  passed  between 
the  head  of  the  humerus  and  the  chest-wall,  consequently  only  the 
shaft  and  lower  portion  of  the  head  can  be  felt  through  the  axilla  ;  but, 
on  the  other  hand,  the  lower  anterior  edge  of  the  glenoid  fossa  and  the 
neck  of  the  scapula  can  sometimes  be  felt  behind  the  shaft. 

Abduction  of  the  limb  is  not  always  easy,  and  is  effected  by  eleva- 
tion of  the  scapula  rather  than  by  movement  of  the  humerus  upon  it. 
Differences  in  length,  when  the  arm  is  dependent,  are  less  constant 
and  marked  than  in  the  preceding  variety,  but  if  the  arm  can  be 
abducted  npon  the  scapula  the  shortening  is  then  greater. 

The  dislocation  can  be  transformed  into  a  subcoracoid  by  traction 
downward  and  outward. 

Occasionally  ^  the  dislocated  arm  is  fixed  in  the  position  of  complete 
horizontal  abduction  (Fig.  396).      Such  are  doubtless  cases  in  which 

Fig,  398. 


Intracoracoid  dislocation,  with  arm  fixed  in  horizontal  abduction.     (BARDENHErER.) 

the  head  has  left  the  socket  at  a  low  point  while  the  arm  was  widely 
abducted.  (See  Subglenoid  Dislocations  and  Luxatio  erecfa,  Chapter 
XLIII.) 

Treatment  of  Anterior  Dislocations. 

(See,  also,  Chapter  XXXIII.) 

Obstacles  to  the  return  of  the  head  of  the  humerus  to  its  socket  may 
be  created  by  the  tension  of  portions  of  the  capsule  which  oppose  its 
movement  tow-ard  the  socket,  except  in  certain  attitudes  of  the  limb. 


Biirdeiiheuer:  Deutsche  Chirurgie,  Lief.  G3  a,  p.  317. 


642  DISLOCATIONS. 

by  the  approximation  of  the  sides  of  the  rent  in  the  capsule  througli 
which  it  "has  passed,  by  the  interposition  of  portions  of  the  capsule  or 
of  the  tendon  of  the  biceps,  by  its  engagement  behind  the  edge  of  the 
glenoid  cavity  or  the  coracoid  process,  by  the  contraction  or  rigidity  of 
the  muscles  and  the  swelling  of  the  soft  parts,  and  exceptionally  by 
the  interposition  of  the  tendon  of  the  subscapularis  (see  above).  Those 
which  are  most  frequently  concerned  are  the  opposition  of  the  anterior 
portion  of  the  capsule  and  the  contraction  of  the  muscles. 

If  the  portion  of  the  capsule  which  extends  from  the  base  of  the 
coracoid  process  and  the  outer,  or  posterior,  edge  of  the  glenoid  fossa 
to  the  greater  tuberosity  and  posterior  portion  of  the  humerus,  includ- 
ing the  coraco-humeral  ligament,  remains  untorn,  it  is  stretched  down- 
ward and  forward  across  the  glenoid  fossa,  and,  being  drawn  tight  by 
the  weight  of  the  elbow,  it  holds  the  head  of  the  humerus  against  the 
scapula.  If  now  the  elbow  is  raised,  the  capsule  is  thereby  relaxed, 
and  the  abducted  limb  can  be  easily  drawn  outw^ard. 

If  the  capsule  is  so  freely  torn  away  from  the  humerus  on  the  outer 
side  that  it  falls  down  between  it  and  the  glenoid  fossa,  it  cannot  be 
lifted  out  of  the  way  by  manipulation  of  the  arm  because  its  separation 
is  so  complete  that  it  is  no  longer  affected  by  the  position  given  to  the 
latter.  It  may,  perhaps,  be  pushed  out  of  the  way  by  the  returning 
bone,  but  that  is  a  matter  of  chance  rather  than  of  skill.  Probably, 
full  abduction  of  the  arm  followed  by  traction  would  be  most  likely  to 
accomplish  the  object  under  such  circumstances. 

Dislocation  and  interposition  of  the  tendon  of  the  long  head  of  the 
biceps  occurs  only  with  avulsion  of  the  greater  tuberosity,  and  not 
always  then,  for  it  may,  instead,  be  ruptured.  Even  when  interposed, 
the  tendon  may  be  fairly  expected  to  have  preserved  its  relations  with 
the  lower  part  of  the  bicipital  groove  and  sheath,  and  consequently  to 
be  still  somewhat  under  control  by  the  humerus.  By  elevating  the 
arm  and  flexing  the  elbow  it  will  be  relaxed  and  raised  toward  the 
upper  part  of  the  joint,  leaving  space  below  for  the  head  of  the  bone 
to  pass  back  under  it. 

Abduction  of  the  arm  and  external  rotation  are,  then,  the  means  by 
which  the  most  common  obstacles  created  by  the  capsule  are  to  be 
avoided. 

The  muscles  oppose  reduction  by  their  contraction  excited  by  pain 
or  the  fear  of  pain  ;  this  can  sometimes  be  avoided  by  taking  the  patient 
unawares,  or  by  fatiguing  the  muscles,  and  always  by  anfesthesia.  A 
certain  anxiety  connected  with  resort  to  the  aid  of  anaesthesia  has  arisen 
from  the  fact  that  a  disproportionate  number  of  deaths  caused  by  chloro- 
form have  occurred  in  the  reduction  of  dislocations  (see  p.  517),  but  I  am 
not  aware  that  death  has  ever  followed  the  use  of  ether  under  such  cir- 
cumstances. There  are  many  reasons  why  reduction  should  be  made, 
when  conveniently  practicable,  without  its  aid,  but  I  never  hesitate  to 
avail  myself  of  the  aid  of  ether  in  preference  to  the  employment  of 
long-continued,  forcible,  or  painful  traction,  even  in  recent  cases.  In 
those  of  long  standing,  in  which  adhesions  must  be  broken,  the  capsule 
retorn,  and  the  shortened  muscles  elongated^  it  is  indispensable. 


ANTERIOR  DISLOCATIONS  OF  THE  SHOULDER.  643 

Reduction  in  recent  cases  is  usually  easy,  and  it  has  been  safely 
accomplished  after  the  la})se  of  many  weeks  and  even  months.  It  is 
impossible  to  fix  a  period  after  which  reduction  by  traction  should  no 
longer  be  attempted  ;  each  case  must  be  judged  by  itself.  Serious,  even 
fatal,  accidents  have  followed  tiie  attempt  so  often  that  the  surgeon  is 
fully  justified  in  advising  abstention  on  the  ground  that  the  risk  is  too 
great  to  be  taken,  and  rapidly  accumulating  experience  shows  that,  at 
least  in  experienced  hands,  reduction  by  open  operation  is  safer  and 
more  successful.     (See  Chapter  XXXIII.) 

Direct  Reposition.  This  method,  the  use  of  which  can  be  traced 
back  to  the  time  of  Avicenna,  has  been  of  late  especially  recommended 
by  Richet  and  Von  Pitha.  It  is  often  successful  in  recent  cases  in 
which  the  displacement  and  muscular  contraction  are  not  great,  and 
especially  when  aided  by  anaesthesia.  The  arm,  somewhat  abducted, 
is  supported  by  the  side,  and  the  surgeon,  placing  his  fingers  in  the 
axilla  on  the  under  and  inner  side  of  the  head  of  the  humerus,  and 
his  thumbs  upon  the  acromion,  seeks  to  press  the  bone  directly  into 
place.  Or  the  position  of  the  hands  may  be  reversed,  the  thumbs 
being  placed  in  the  axilla  and  the  fingers  upon  the  acromion.  Or,  the 
patient  being  seated,  the  surgeon  supports  the  flexed  elbow  upon  his  own 
forearm,  gets  his  fingers  around  the  head  of  the  humerus  in  the  axilla, 
and  presses  it  toward  the  glenoid  cavity  while  he  steadies  the  scapula 
with  the  other  hand. 

Traction  Downward  and  Outward  with  Coaptation.  In  its  simplest 
form,  one  that  is  successful  in  a  large  proportion  of  cases,  especially 
with  the  aid  of  anaesthesia,  the  method  is  practised  as  follows :  The 
patient  is  placed  upon  a  bed  and  counter-extension  is  provided  by  a 
band  ])assed  around  his  chest  and  made  fast  to  a  support  on  the 
sound  side.  If  anaesthesia  is  used  the  weight  of  the  body  is  usually 
suflicient  for  counter-extension,  and  this  band  can  be  dispensed  with. 
The  surgeon  grasps  the  arm  above  the  elbow  and  pulls  steadily  down- 
ward and  outward  at  first,  and  then  slowly  changes  the  direction  by 
increasing  the  abduction  until  the  arm  is  nearly  or  quite  at  right  angles 
with  the  body,  while,  at  the  same  time,  he  rotates  the  arm  outward. 
Or  the  traction  is  made  by  an  assistant,  and  the  surgeon,  standing 
beside  the  patient,  watches  the  movement  of  the  head  of  the  humerus, 
and  when  it  has  approached  the  joint  he  presses  it  upward  into  place 
with  his  fingers  or  thumb,  making  counter-pressure  on  the  acromion. 

If  anaesthesia  is  not  used,  or  if  more  force  is  used,  the  scapula  may 
be  fixed  by  bands  passing  over  and  under  the  shoulder  or  by  pressure 
against  the  edge  of  the  acromion.  Or  the  patient  can  be  laid  on  his 
back  on  the  floor,  and  the  surgeon  seated  beside  him  places  his  foot 
against  the  side  of  the  chest  or  the  edge  of  the  acromion  and  draws  the 
arm  directly  outward. 

It  is  desirable  that  the  elbow  shall  be  kept  partly  flexed  to  relax  the 
biceps,  and  also,  if  tiie  surgeon  himself  is  making  traction,  to  enable 
him  to  rotate  the  limb  inward  when  the  head  has  been  brougiit  close 
to  its  socket,  since  this  niana'uvre  is  sometimes  an  efficient  substitute 
for  direct  pressure  upon  the  iiead. 


644 


DISLOCATIONS. 


I^  have  of  late  (1899j  employed  with  uniform  success  iu  about  a 
dozen  cases  a  method  of  making  this  traction  which  is  easy,  expedi- 
tious, and  apparently  safe.  A  round  hole  six  inches  in  diameter  is 
made  in  the  middle  line  of  a  canvas  cot  about  eighteen  inches  from  one 
end.  and  through  this  hole  the  injured  limb  is  passed  so  as  to  hang 
vertically  downward,  the  patient  lying  on  his  side  on  the  cot  (Fig. 
397).  To  the  limb,  at  the  wrist  or  elbow,  is  attached  a  weight  of 
about  ten  pounds,  and  the  cot  is  raised  upon  blocks  so  that  the  arm  will 
hang  free  of  the  floor.     In  a  few  minutes,  never  more  than  six  in  my 

Fig.  397. 


Reduction  of  anterior  dislocation  of  the  shoulder. 

experience,  reduction  of  the  dislocation  takes  place  quietly  and  without 
pain  during  the  waiting.  Instead  of  a  cot,  the  patient  might  perhaps 
be  put  upon  two  tables  placed  end  to  end  so  that  the  body  would  rest 
on  one  and  the  head  on  the  other,  the  arm  hanging  down  between,  but 
possibly  the  lack  of  snug  support  of  the  shoulder^  and  the  consequent 
muscular  effort  to  maintain  the  position,  would  interfere  with  success 
or  at  least  delay  it.  Continuous  traction  by  India-rubber  or  a  weight 
and  pulley,  as  described  on  page  522,  acts  in  the  same  gentle  manner. 
Another  modification  is  the  so-called  " pendel-methode/'  which  occu- 
pies a  position  intermediate  between  the  above  and  the  following 
method,  hyper-elevation  of  the  arm,  and  in  which  the  weight  of  the 
patient's  body  is  used  to  make  the  traction.  The  ])atient  is  laid  upon 
»  Stimson  :  Med.  Eecord,  March  3,  1900- 


ANTERIOR   DISLOCATIONS   OF  THE  SHOULDER.  645 

the  floor  on  the  sound  side,  and  an  assistant,  standing  upon  a  stool, 
grasps  the  dislocated  arm  and  lifts  the  shoulders  from  the  floor  while 
the  surgeon  presses  the  head  of  the  bone  toward  its  socket.  If  a  greater 
weight  is  needed  another  assistant  raises  the  feet  so  that  the  body  is 
wholly  oif  the  floor,  or  presses  downward  against  the  side  of  the  chest. 
If  a  sufficiently  robust  assistant  is  not  at  hand,  or  if  the  effbrt  is  to  be 
prolonged,  the  suspension  may  be  made  by  means  of  a  rope  attached  to 
the  arm  above  the  elbow.  Bardenheuer  says  that  Simon  reduced  by 
this  means  a  dislocation  that  had  existed  for  a  year  and  three-(iuarters. 

Traction  Upward.  In  this  method  the  arm  is  raised  beside  the  head 
and  drawn  upon  while  counter-extension  is  made  by  the  hand  or 
foot  upon  the  top  of  the  shoulder.  Duplay,  following  Malgaigne, 
speaks  of  it  in  rather  exaggerated  terms  as  the  only  rational  method, 
because  it  relaxes  all  the  muscles.  The  difference  between  it  and  trac- 
tion at  right  angles  to  the  body  is  more  apparent  than  real,  because  the 
further  elevation  of  the  arm  is  effected  by  a  change  in  the  position  of 
the  scapula  npon  the  chest,  without  change  in  its  relations  to  the 
humerus.  The  method  which  was  known  to  Celsus  and  practised  by 
Brunus  in  the  thirteenth  century,  was  extensively  used  in  England  in 
the  last  century,  but  is  more  particularly  connected  with  the  name  of 
Mothe  in  France,  and  of  Kluge  in  Germany.  Malgaigne  says  that 
he  himself  reinvented  it  for  the  fourth  or  fifth  time  in  1828  as  the 
result  of  experiments  upon  the  cadaver.  It  has  commonly  been  com- 
bined in  practice  with  some  form  of  the  method  next  to  be  described, 
the  bascule  of  the  French  and  German  authors,  that  in  which  the  head 
of  the  bone  is  pressed  outward  by  placing  a  fulcrum  high  np  in  the 
axilla  and  then  swinging  the  elbow  in  toward  the  body,  and  has  also 
been  frequently  supplemented  with  external,  followed  by  internal, 
rotation. 

In  its  simplest  form,  as  described  by  Bransby  Coojier,  the  patient  is 
placed  upon  his  back  on  the  bed  or  table,  and  the  surgeon  sitting  beside 
his  head  draws  the  dislocated  arm  upward  with  one  hand  and  fixes  the 
scapula  with  the  other ;  the  counter-extension  may  be  aided  by  a  long 
bandage  or  towel  passing  over  the  shoulder  and  fixed  by  both  ends  to 
the  foot  of  the  bed.  After  reduction  has  taken  place,  and  while  the 
arm  is  being  lowered,  the  head  of  the  humerus  should  be  held  in  place 
by  direct  pressure  upon  it. 

Malgaigne's  plan,  when  more  force  was  needed,  was  to  rest  the 
patient  on  the  floor,  and  lift  the  arm  directly  upward  with  both  hands, 
counter-extension  being  made  by  the  weight  of  the  body  and  aided,  if 
necessary,  by  pressure  made  upon  the  acromion  by  an  assistant.  If 
this  failed  and  he  wished  to  try  more  force  before  resorting  to  the 
bascule,  he  made  the  patient  stand  beside  a  door  and  raised  the  arm  to 
a  vertical  position  by  means  of  a  strong  band  made  fast  at  the  wrist  or 
elbow  and  carried  over  the  top  of  the  door  ;  then  the  patient  was 
directed  to  bend  his  knees  until  the  weight  of  his  body  should  be 
entirely  supported  by  the  dislocated  arm,  and,  in  addition,  the  surgeon 
contributed  his  own  weight  by  clasping  his  hands  over  the  patient's 
acromion  and  kneeling  beside  him.    The  addition,  proposed  by  Lacour* 

'  Lacour:  Mem.  dc  Chiiurgie,  lbl7,  vol.  i.  p.  387. 


646  BISL  0  CA  TIONS. 

in  1847,  of  external  and  internal  rotation  to  the  vertical  traction,  has 
added  to  its  efficiency. 

The  chief  objection  to  this  method  is  that  mentioned  in  connection 
with  the  preceding  one,  the  risk  of  injuring  the  main  vessels  in  the 
axilla  by  unduly  stretching  them  around  the  head  of  the  humerus, 
and  it  is  even  greater  here  because  the  elevation,  or  abduction, 
is  made  without  preliminary  traction  to  bring  the  head  nearer  the 
socket. 

Another  objection  is  that  it  is  likely  to  increase  the  laceration  of  the 
capsule  and  of  the  subscapularis  and  thereby  promote  recurrence  of  the 
dislocation. 

Traction  with  Leverage.  This  method  differs  from  that  of  traction 
downward  and  outward  in  the  addition,  or  the  substitution  for  direct 
coaptative  pressure  by  the  hands,  of  a  leverage  movement  in  which 
the  head  of  the  bone  is  forced  outward  by  the  adduction  of  the  limb 
over  a  fulcrum  placed  in  the  axilla.  The  fulcrum  is  usually  the 
closed  fist  or  the  heel. 

When  the  hand  is  used  traction  is  made  outward  and  downward  by 
an  assistant,  and  when  the  head  of  the  bone  has  been  moved  sufficiently 
far  the  surgeon  places  his  closed  fist  well  up  in  the  axilla,  and  the 
assistant,  still  maintaining  the  traction,  swings  the  arm  toward  the  side 
(adduction),  sometimes  combining  with  it  moderate  rotation. 

The  Heel  in  the  Axilla.  This  method,  generally  known  as  Sir  Astley 
Cooper's,  but  really  dating  back  to  the  time  of  Hippocrates,  was  in 
very  general  use  in  England  and  America  until  quite  recently.  It  is 
unfortunately  responsible  for  not  a  few  more  or  less  serious  injuries  to 
the  bloodvessels  and  nerves  of  the  axilla. 

^rhe  patient  is  placed  upon  his  back  on  a  bed  or  sofa  and  a  towel  or 
stout  bandage  made  fast  to  the  arm  above  the  elbow.  The  surgeon, 
facing  him,  seats  himself  upon  the  side  of  the  bed  and  places  the  heel 
of  one  foot,  from  which  the  shoe  has  been  removed,  well  up  in  the 
axilla  against  the  head  of  the  humerus  and  then  makes  traction  doM^n- 
ward  upon  the  towel  and  maintains  it  until  the  bone  is  felt  to  slip  into 
place.  Remembering  that  under  these  conditions  traction  upon  the 
humerus  is  directly  transmitted  to  the  scapula  through  the  already 
tense  capsule,  it  seems  probable  that  the  method  owes  its  efficiency  to 
the  action  of  the  heel  as  a  wedge,  which  by  being  forced  in  between 
the  thorax  and  the  humerus  presses  the  latter  directly  outward.  If 
the  traction  is  made  at  first  in  a  direction  inclined  away  from  the  body, 
and  then  brought  more  nearly  parallel  to  it,  the  mechanical  eifect  is 
the  same  as  when  the  fist  is  used  as  above  described. 

It  may  be  proper  to  employ  this  method  if  no  more  force  is  used 
than  can  be  exerted  by  the  surgeon  himself,  although  accidents  have 
happened  even  under  such  circumstances,  but  it  is  certainly  dangerous 
and  improper  to  employ  it  with  the  pulleys  or  assistants,  and  still  more 
so  to  substitute  an  iron  plug  for  the  heel  as  recommended  and  prac- 
tised by  Skey.  The  large  vessels  and  nerves  lie  upon  the  inner 
side  of  the  head  of  the  humerus  and  are  exposed  to  be  compressed 
between   it  and  the  heel  and  thus  directly  bruised    or   so    held    fast 


ANTERIOR  DISLOCATIONS   OF  THE  SHOULDER.  647 

that  they  may  be  overstretched  and  torn  as  their  distal  portions  are 
drawn  downward  in  the  sliding  of  the  soft  parts  of  the  arm  toward 
the  elbow. 

Forcible  Traction.  If  more  forcible  traction  is  needed  than  can  be 
made  in  the  methods  already  described,  resort  should  lie  had  to  the 
pulleys  or  specially  constructed  apparatus.  The  pulleys  are  made  fast 
to  the  arm  above  the  elbow  by  a  broad  leather  band  buckled  tightly 
around  it  or  by  a  strap  or  band  made  fast  by  several  turns  of  a  wet 
bandage.  As  a  further  precaution  against  slipping  the  forearm  should 
be  bandaged  and  the  elbow  fixed  at  a  right  angle.  It  is  also  advisable 
to  interpose  a  dynamometer  between  the  pulleys  and  the  limb  to  indi- 
cate the  amount  of  force  that  is  being  employed,  and  a  pair  of  "  liber- 
ation forceps"  to  allow  the  traction  to  be  suddenly  relaxed  and  the 
position  of  the  arm  changed. 

The  special  instruments,  of  which  the  most  elaborate  and  ingenious 
are  made  in  France,  are,  in  the  main,  modifications  of  the  ''adjuster" 
invented  by  Dr.  Jarvis,  of  Portland,  Connecticut.  They  consist  of 
two  l)ars  movable  upon  each  other  by  a  rack  and  pinion,  one  of  which 
is  made  fast  by  a  leather  bracelet  to  the  lower  part  of  the  arm,  and  the 
other  to  a  ring  or  crutch  that  fits  against  the  scapula.  A  dynamom- 
eter indicates  the  force  exerted,  and  a  catch  sets  it  instantly  free  at 
will.  The  instruments  are  expensive,  the  occasions  for  their  use  are 
rare,  and  tlie  method  is  dangerous. 

Reduction  by  Manipulation.  (Rotation.)  It  has  been  already  men- 
tioned that  rotation  of  the  arm  has  long  been  used  in  connection 
with  the  various  methods  of  extension  to  effect  reduction,  and  it  also 
appears  that  from  time  to  time  men  have  sought  to  reduce,  and  some- 
times with  success,  by  moving  the  limb  in  various  directions  without 
the  aid  of  much  traction,  but  it  is  only  within  the  present  century  that 
methods  of  manipulation  founded  upon  a  correct  appreciation  of  the 
obstacles  and  of  the  means  by  which  they  may  be  overcome  have  been 
devised  and  practised  with  intelligence  and  success.  Rotation  inward 
was  long  employed  as  the  final  manoeuvre  to  turn  the  head  of  the  bone 
into  the  socket  after  it  had  been  brought  opposite  it  by  traction,  and  it 
still  constitutes  the  final  step  in  the  pure  manipulative  method.  Exter- 
nal rotation  during  traction  was  first  employed  under  the  influence  of 
various  ideas  concerning  the  part  taken  by  the  muscles  in  opposing  the 
return  of  the  bone,  or  to  dislodge  the  head  from  its  position  behind  the 
lip  of  the  glenoid  fossa  ;  then,  in  the  light  of  more  accurate  knowledge 
of  the  influence  of  the  untorn  portion  of  the  capsule,  it  became  the  first 
step  in  the  methods  of  reduction  without  traction. 

Of  these  methods  the  one  most  highly  esteemed  and  generally  prac- 
tised is  that  recommended  by  Prof.  Kocher,^  of  Bern.     The  follow-        ,  / 
ing  description  is  taken   from  one  given  at  the  Surgical  Congress  in      W 
London,  and  published  by  his  pupil  Ceppi  in  the  Revue  de  Chinor/ie,     ^\ 
1882,  p.  831:  "In  the  subcoracoid  dislocation  the  posterior  portion        \\ 

1  Koclier  :  Berlin,  klin.  Wocheuschrift,  1870,  No.  9,  aud  Volkmaiiii'.s  .Sanuuluiig  kliu, 
Vortrage,  No.  83,  p.  611. 
45 


648 


DISLOCATIONS. 


of  the  capsule  and  the  tendons  of  the  posterior  scapular  muscles  which 
cover  and  streng^then  it  are  untorn  and  are  stretched  over  the  glenoid 
fossa.  The  inferior  portion  of  the  capsule  which  forms  the  lower  bor- 
der of  the  rent  is  also  very  tense.  But  the  tension  is  greatest  at  the 
upper  part  of  the  capsule,  and  especially  between  the  long  tendon  of 
the  biceps  and  the  upper  border  of  the  subscapularis,  where  it  is 
reinforced  by  the  fibres  of  the  coraco-humeral  ligament.  This  portion 
of  the  capsule  is  twisted  in  the  dislocation,  and  stretched  in  the  form 
of  a  solid  cord.     If  now  the  humerus  is  rotated  externally  until  the 

Fig.  398. 


Kocher's  method  of  reduction  by  manipulation :  1st  movement,  outward  rotation.    (Ceppi.) 

flexed  forearm  is  turned  directly  outward,  this  cord  will  be  at  the  same 
time  rotated  outward,  the  posterior  part  of  the  capsule  will  be  widely 
removed  from  the  fossa,  and  the  rent  in  the  capsule  will  gape ;  but  the 
head  of  the  humerus  will  still  remain  solidly  fixed  against  the  anterior 
edge  of  the  glenoid  fossa  because  the  upper  and  lower  portions  of  the 
capsule  have  not  been  relaxed  by  this  movement.  It  is  only  when 
the  elbow  is  carried  forward  and  raised  in  the  sagittal  plane,  while  the 
arm  is  still  held  in  external  rotation,  that  the  upper  part  of  the  capsule 
is  seen  to  relax,  and  the  head  of  the  humerus,  thanks  to  the  tension  of 
the  lower  portion  which  keeps  it  from  moving  forward,  to  enter  its 
socket.     Rotation  inward  then  completes  the  reduction." 

The  method  may  be  formulated  in  detail  as  follows :  Dislocation 
of  the  left  shoulder.  The  patient  is  seated,  and  the  surgeon,  kneel- 
ing beside  him,  flexes  his  elbow  at  a  right  angle  and  presses  it  with 
his  right  hand  against  his  side ;  then,  holding  the  elbow  firmly  in 
place,  he  slowly  and  steadily  moves  the  wrist  outward  with  his  left 
hand  (external  rotation  of  the  humerus)  until  the  forearm  stands 
directly  outward  from  the  side  of  the  body ;  if  this  is  strongly  re- 
sisted the  pressure  must  be  steadily  maintained  until  the  resistance 
yields.  The  evidence  that  the  movement  has  accomplished  what  was 
expected  of  it  is  the  appearance  of  greater  fulness  of  the  outer  deltoid 
region  ;  if  this  does  not  appear  the  attempt  will  fail.  Then,  still  main- 
taining the  external  rotation  of  the  arm  and  the  flexion  of  the  elbow,  the 


ANTERIOR  DISLOCATIONS  OF  THE  SHOULDER. 


G49 


surgeon  moves  the  elbow  forward,  or  forward  and  slightly  inward,  until 
the  arm  is  nearly  horizontal  ;  during  this  movement  the  fulness  of  the 
outer  deltoid  region  becomes  more  marked,  and  at  its  termination  the 
manoeuvre  is  completed  by  rotating  the  arm  inward  and  bringing  the 
hand  to  the  opposite  shoulder.  The  bone  may  slip  into  place  during 
the  second  movement,  elevation  of  the  elbow.  Direct  traction  out- 
ward of  the  upper  end  of  the  bone  by  a  bandage  in  the  axilla  is  some- 
times helpful,  and  I  have  sometimes  found  it  advantageous  to  make 

Fig.  399. 


Kocher's  method  of  reduction    2d  movement,  elevation  of  elbow.    (Ceppi.) 

firm  pressure  downward  at  the  elbow  (traction  in  the  long  axis  of  the 
arm)  during  the  movement  of  outward  rotation. 

The  method  as  thus  described  is  applicable  to  those  cases  in  which 
the  displacement  is  neither  very  far  inward  nor  low  down,  in  short, 
to  the  higher  forms  of  the  subcoracoid  variety  ;  and  as  it  depends  for 
its  success  upon  the  resistance  of  the  untorn  portion  of  the  capsule  it 
will  fail  whenever  the  capsule  is  very  extensively  torn.  When  the 
displacement  is  far  inward  or  low,  traction  upon  the  abducted  limb 
is  more  likely  to  succeed. 

Konig^  modifies  it  for  the  lower  anterior  and  subglenoid  dislocations 
by  making  traction  in  abduction,  rotating  outward,  and  then  adduct- 
ing.  This  is  practically  the  same  as  the  method  described  as  traction 
downward  and  outward  and  generally  known  as  Lacour's  method  by 
manipulation. 

Farabenf^  studied  Kocher's  method  experimentally  with  a  view  to 
determine  the  mechanism  by  which  its  result  was  accomj)lished,  and 
reached  the  conclusion  that  the  efficient  agent  was  the  untorn  jiosterior 
portion  of  the  capsule,  and  that  the  upper  portion,  the  coraco-humeral 
ligament,  had  little  or  nothing  to  do  with  it.  He  showed,  experi- 
mentally, that  when  this  latter  had  been  divided  and  the  posterior  por- 
tion left  intact  the  mananivre  woidd  still  effect  reduction,  but  that  when 
the  posterior  portion  was  divided  and  the  upper  portion  left  whole  it 

'  Konig:  Speciel.  Chirurgie,  3d  ed.,  vol.  iii.  p.  40. 
*  Fanibcnf :  Bull,  de  la  Soc.  de  Chir.,  1885,  p.  395. 


650 


DISLOCATIONS. 


failed,  and  that  then  the  head  of  the  humerns  instead  of  being  moved 
ontward  by  the  external  rotation  simply  revolved  about  the  longitu- 
dinal axis  of  the  shaft.  His  explanation  is  clear  and  intelligible. 
According  to  it  the  approximation  of  the  elbow  to  the  side  tightens  the 


Fig.  400. 


Kocher's  method  of  reduction  :  3d  movement,  inward  rotation  and  lowering  of  elbow.    (Ceppi.) 

posterior  portion  of  the  capsule  where  it  extends  between  the  posterior 
lip  of  the  glenoid  fossa  and  the  lower  and  back  part  of  the  neck  of 
the  humerus;  this  prevents  the  posterior  surface  of  the  humerus  from 
moving  inward  when  the  arm  is  rotated  outward,  and  consequently  its 
attachment  to  the  humerus  serves  as  the  fixed  point  or  centre  about 
which  the  bone  rolls  outward,  winding  itself,  as  it  were,  upon  the  cap- 
sule. The  elevation  and  adduction  of  the  elbow,  turning  npon  the 
same  fixed  point,  then  throws  the  head  backward  and  further  outward, 
and  finally  the  internal  rotation  unwinds  the  capsule  and  leaves  every- 
thing in  place. 

The  method  is  applicable  to  old  as  well  as  to  recent  cases,  but  the 
danger  of  breaking  the  humerus  during  the  second  step — outward  rota- 
tion— must  be  borne  in  mind,  especially  in  elderly  patients. 

Schinzinger's  method,  the  introduction  of  which  appears  to  have  ante- 
dated Kocher's,  was  in  like  manner  based  upon  the  persistence  of  the 
posterior  portion  of  the  capsule,  but  differed  from  Kocher's  in  the 
second  and  third  steps  of  the  manoeuvre.  He  rotated  the  arm  outward 
until  the  hand  was  as  far  back  as  the  elbow,  and  then  either  pressed 
the  bone  upward  and  outward  into  place  by  direct  pressure,  or  turned 
it  in  by  slow  internal  rotation  while  an  assistant  made  pressure  on  the 
inner  side  of  its  head  to  prevent  it  from  slipping  back  into  the  position 
from  which  it  had  been  removed  by  the  outward  rotation.  The  method 
is  favorably  spoken  of  by  several  of  the  later  German  writers,  and  is 


ANTERIOR  DTSLOCATIOys   OF  THE  SHOULDER.  051 

thought  to  be  especially  useful  in  rupturing  the  adhesions  of  old  dislo- 
cations without  the  risk  of  injury  to  the  vessels  or  nerves. 

Circumduction,  sonietiiues  known  as  Heine's  method,  in  which,  after 
fixation  of  the  scapula  as  for  traction,  the  arm  is  slowly  abducted,  raised 
to  the  side  of  the  head,  inclined  slightly  backward,  and  then  brought 
forward  and  downward  across  the  face  and  chest,  has  been  recom- 
mended and  used  in  old  dislocations  ;  it  is  undoubtedly  efficient  in 
breaking  up  the  adhesions,  but  it  is  a  rough,  uncertain,  and  dangerous 
plan,  and  should  be  condemned. 

To  recapitulate,  the  treatment  of  a  recent  anterior  dislocation  of 
average  displacement  may  be  thus  summed  up :  Kocher's  method  may 
first  be  tried  ;  if  that  fails,  traction  downward  and  outward  by  one  of 
the  various  methods  should  be  tried,  the  elbow  not  being  raised  higher 
than  the  shoulder,  combined  with  direct  pressure  upon  the  head,  or 
followed  by  adduction  over  the  fist  in  the  axilla.  If  these  also  fail, 
the  patient  should  be  etherized,  and  the  attempt  repeated.  When 
those  rare  conditions  are  present  which  make  reduction  otherwise 
impossible — interposition  of  capsule  or  tendon  of  biceps  or  subscapu- 
laris — an  open  arthrotomy  is  justifiable  if  it  can  be  done  with  proper 
precautions  against  infection. 

In  older  dislocations  the  same  plan  should  be  followed,  and  resort 
should  be  had  to  forcible  traction  only  after  other  measures  have  failed. 

The  signs  of  a  successful  reduction  are  the  sound  that  is  usually 
heard  when  the  bone  slips  into  place,  the  restoration  of  form  and  func- 
tion, and  the  diminution  or  cessation  of  pain.  The  sound  is  not  always 
heard;  and,  on  the  other  hand,  a  similar  sound  may  be  caused  by  the 
rupture  of  adhesions  or  by  the  slipping  of  the  bones  upon  each  other. 
Complete  restoration  of  form  is  the  best  evidence  ;  this  is  to  be  deter- 
mined by  an  examination  similar  to  that  employed  in  making  the 
diagnosis  of  a  dislocation  and  by  attention  to  the  same  signs.  The 
reduction  may  be  incomplete  because  of  the  interposition  of  a  portion 
of  the  capsule,  or  because  of  the  presence  of  tissues  of  new  formation 
in  the  glenoid  cavity.  This  incompleteness  is  shown  by  the  abnormal 
projection  forward  of  the  head  of  the  humerus  under  the  acromion. 

After-treatment. 

After  reduction  has  been  obtained  it  is  highly  desirable  that  the 
arm  should  be  immobilized  for  two  or  three  weeks  in  a  position 
that  will  favor  the  speedy  repair  of  the  lacerations  of  the  capsule, 
tendons,  and  muscles ;  otherwise  the  joint  may  remain  in  a  con- 
dition that  favors  recurrence,  and  the  patient  may  suffer  nuich  in- 
convenience or  even  disability  in  consequence.  As  the  rent  in  the 
capsule  is  on  the  inner  side,  and  as  its  edges  are  separated  by  external 
rotation  of  the  limb,  the  head  of  the  humerus  should  be  directed 
toward  the  outer  side  (adduction  of  the  elbow)  and  the  arm  should  be 
kept  rotated  inward.  These  two  indications  are  met  by  binding  the 
limb  to  the  l)ody  with  the  hand  resting  just  below  the  opi)osite  clavicle. 
Fixation  may  be  made  by  a  starch  or  ])"laster-of-Paris  dressing  or  even 
by  simple  bandages,  but  the  most   convenient  and   effective  dressing 


652  DISLOCATIONS. 

is  a  strip  of  adhesive  plaster  arranged  as  follows  :  beginning  in  front 
at  the  clavicle  it  is  carried  over  the  shoulder  and  down  the  back 
of  the  arm,  then  under  the  elbow  to  the  back  of  the  forearm,  and 
along  the  latter  and  the  back  of  the  hand  to  and  over  the  top  of  the 
opposite  shoulder.  A  small  pad  of  absorbent  cotton  or  lint  should  be 
placed  in  the  axilla  and  between  surfaces  of  skin  that  are  in  contact. 
If  the  patient  is  unruly  a  second  band  may  be  placed  circularly  about 
the  body  and  lower  part  of  the  arm.  This  dressing  should  be  retained 
for  two  or  three  weeks,  and  the  arm  carried  in  a  sling  for  a  fortnight 
longer.  If  passive  motion  is  made,  abduction  and  external  rotation 
should  be  avoided. 

For  complications,  accidents,  prognosis,  and  the  treatment  of  old 
dislocations,  see  Chapter  XLIV. 


CHAPTER  XLIII. 

DISLOCATIONS  OF  THE  SHOULDER.— (Continued.) 

Downward  Dislocations :   Subglenoid,  erecta,  subtricipital — Posterior   Disloca- 
tions:  Subacromial,  subspinous,  upward  dislocations. 

DOWNWARD  DISLOCATIONS. 


1.  Subglenoid. 

Under  this  title  are  here  included  those  rare  cases  in  which  the 
head  of  the  humerus  is  displaced  directly  downward  upon  the  tendon 
of  the  long  head  of  the  triceps,  and  those  more  frequent  ones  in  which 
it  is  engaged  under  the  lower  and  inner  edge  of  the  glenoid  cavity, 
and  rests  against  the  flattened  upper  portion  of  the  axillary  border  of 
the  scapula  on  the  inner  side  of 

the  tendon  of  the  triceps.     As  Fig.  401. 

explained  in  connection  with 
the  classification  given  in  the 
preceding  chapter,  the  name  is 
here  restricted  to  a  portion  of 
those  cases  which  are  termed 
subglenoid  by  most  English 
and  American  authors,  to  those, 
namely,  in  which  the  head  of 
the  bone  is  low  in  the  axilla. 
By  some  the  term  is  still  further 
restricted  in  use,  and  is  applied 
only  to  the  first  of  the  two 
forms  above  mentioned,  those 
in  which  the  head  is  displaced 
directly  downward  upon  the 
tendon  of  the  triceps.  Although 
it  is  denied  by  some  on  theo- 
retical grounds  that  this  form 
can  exist,  yet  it  must  be  ad- 
mitted not  only  as  possible,  but  as  having  been  actually  observed,  on 
the  evidence  of  several  observers  who  fully  understood  the  point  in 
dispute.  Von  Pitha  (quoted  by  Bardonheuer)  says  that  he  had  seen 
it  only  in  cases  in  which  he  had  the  o]>]>ortunity  to  examine  the  ])atient 
immediately  after  the  accident,  and  before  any  movements  liad  been 
communicated  to  the  limb  or  attcm])ts  made  to  reduce.  He  believes 
that  the  head  can  be  easily  displaced  from  its  new  position,  and  moved 
upward  and  forward,  the  dislocation  being  thus  transformed  into  a  sub- 
coracoid,  by  involuntary  or  communicated  movements  of  the  arm,  or 

( 053  ) 


Subglenoid  dislocation. 


654 


DISLOCATIONS. 


even  by  muscular  action.  Tillaux  '  observed  this  transformation  in  a 
case  while  he  was  preparing  to  make  a  cast  of  the  limb. 

Two  varieties,  representing  extreme  displacements,  and  characterized 
by  exceptional  symptoms,  the  luxatio  erecta  and  the  mbtricijntal  (?), 
will  be  separately  described. 

This  form  of  dislocation  was  studied  experimentally  by  Malle,^ 
Goyrand,^  and  Panas.^  They  found  that  if  the  scapula  was  fixed  and 
the  arm  was  firmly  elevated,  the  head  of  the  humerus  presented 
through  a  large  rent  in  the  capsule  between  the  subscapularis  and  the 
long  head  of  the  triceps,  and  that  if  the  arm  was  then  lowered  the 
head  would  often  return  to  its  socket,  but  that  if  it  was  twisted  out- 
ward while  being  loAvered  the  dislocation  would  persist.  The  lower 
border  of  the  subscapularis  was  always  found  torn  and  its  untorn  por- 
tion rested  upon  the  upper  surface  of  the  head  ;  and  Malle  claimed  that 
in  order  to  produce  the  dislocation  upon  the  cadaver  it  was  necessary 
to  divide  the  portion  of  the  capsule  between  the  acromion  and  the 
lesser  tuberosity. 

The  cause,  with  the  single  exception  of  Desault's  doubtful  case,  in 
which  the  injury  was  said  to  have  been  produced  by  a  fall  upon  the 
shoulder,  has  always  been  the  forcible  elevation  of  the  arm,  as  in  a  fall 
through  a  narrow  opening  or  upon  the  extended  elbow,  by  a  horse 
throwing  up  his  head  while  being  led  by  the  bridle,  or  as  in  Goyrand's 
case  of  a  woman  who,  having  fallen  to  the  ground,  had  her  arm  dislo- 
cated by  a  passer-by  who  sought  to  raise  her.  In  one  of  Tillaux's 
cases  a  young  girl  dislocated  her  shoulder  by  suddenly  raising  her  arm 
while  playing  at  raquettes.  Probably  my  case  in  which  the  head  of 
the  humerus  lay  on  the  inner  side  of  the  subscapularis  was  primarily 
of  this  kind,  the  head  having  passed  upward  and  inward  when  the 
arm,  which  had  been  forcibly  raised  in  lifting  the  patient  from  the 
water,  was  lowered. 

The  rent  in  the  capsule  in  the  specimens  produced  experimentally 
has  always  been  comparatively  small,  and  situated  in  the  lower  and 
inner  portion  between  the  triceps  and  the  subscapularis,  and  differs 
from  that  of  the  subcoracoid  form  in  not  extending  so  far  upward 
along  the  anterior  edge  of  the  glenoid  cavity.  In  a  specimen  presented 
by  Leroy^  to  the  Societe  Anatomique  the  lesions  were  identical  with 
those  produced  experimentally.  The  upper  part  of  the  capsule,  includ- 
ing the  insertion  of  the  supraspinatus  and  infraspinatus  muscles,  M^as 
torn  away  from  the  humerus,  from  the  anterior  border  of  the  bicipital 
groove  to  the  tendon  of  the  teres  minor,  a  distance  of  four  centimetres ; 
in  the  lower  portion  was  the  usual  rent,  two  and  three-quarters  inches 
long,  extending  from  the  tendon  of  the  teres  minor  inward  and  then 
upward  along  the  anterior  border  of  the  glenoid  cavity.  The  head  of 
the  humerus  lay  upon  the  axillary  border  of  the  scapula  one  inch  below 
the  anterior  border  of  the  coracoid  process,  the  limb  being  so  far  rotated 
outward  that  the  internal  epicondyle  was  directed  forward,  and  the 
greater  tuberosity  rested  against  the  anterior  lip  of  the  axillary  border 

'  Tillaux  :  Auat.  topographique.  p.  536. 

2  Malle:  Bull,  de  I'Acad.  de  Med.,  Paris,  1838,  vol.  ii.  p.  941. 

'   Goyraiid  :  Mem.  de  la  Soc.  de  Chiv.,  1847,  vol.  i.  p.  21. 

*  Paiias :  Diet,  de  Med.  et  Chir.  pratiques,  art.  Epaule,  p.  462. 

*  Leroy  :  Bull,  de  la  Soc.  Anatomique,  1844,  p.  102. 


DOWNWARD  DISLOCATIONS  OF  THE  SHOULDER. 


655 


and  the  adjoining  portion  of  the  neck  of  the  scapula.  The  subscapu- 
laris  was  pushed  upward  and  overlapped  the  head.  In  another  reported 
to  the  same  society  by  Bouygues  ^  the  head  of  the  humerus  lay  below 
and  in  front  of  the  glenoid  fossa  and  beneath  the  nntorn  subscapularis, 
the  anatomical  neck  resting  on  the  axillary  border  of  the  scapula  and 
the  lower  part  of  the  fibro-cartilaginous  rim  ;  the  upper  portion  of  the 
greater  tuberosity  was  broken  off. 

In  a  case  reported  by  Jossel^  of  subglenoid  dislocation  caused  by  a 
fall  from  the  second  story  of  a  house,  in  which  death  followed  on  the 
second  day  in  consequence  of  an  associated  fracture  of  the  skull,  the 
following  conditions  were  found  :  The  subscapular  artery  was  entirely 
torn  across.  The  head  of  the  humerus  lay  between  tlie  partly  torn  sub- 
scapularis muscle  and  the  triceps  "  upon  the  triangular  surface  of  the 
lower  border  of  the  scapula  directly  below  the  glenoid  fossa."  The 
capsule  was  entirely  torn  from  the  humerus,  the  subscapularis  was 


Fig.  402. 


Subglenoid  dislocation.    (From  a  photograph.) 

pushed  upward,  the  edge  of  the  glenoid  fossa  was  a  little  broken  at  its 
widest  part,  and  the  upper  and  middle  facets  of  the  greater  tuberosity 
were  broken  off,  the  line  of  fracture  running  into  and  opening  the 
bicipital  groove. 

In  Sedillot's  case,  quoted  by  Malgaigne  as  of  this  kind,  the  condi- 
tions were  quite  exceptional ;  abduction  was  so  marked  that  the  arm 
was  held  almost  horizontal,  the  head  of  the  humerus  was  situated  half 
an  inch  below  the  glenoid  fossa,  resting  against  the  scapula,  but  also 

'  Bouygues:  Ibid.,  1888,  p.  581. 

2  Jossel  :  Deutsche  Zeitschrift  fiir  Chirurgie,  1871,  vol.  iv.  ]).  124. 


656  DISLOCATIONS. 

engaged  between  the  latissimiis  dorsi  and  teres  major  in  front  and  the 
triceps  behind. 

Apparently  the  failure  of  the  head  to  rise  as  usual  to  the  level  which 
would  make  the  dislocation  subcoracoid  is  due  to  the  resistance  of  the 
untorn  portion  of  the  capsule  on  the  inner  side  ;  and  the  greater  abduc- 
tion of  the  limb  is  due  to  this  retention  of  the  head  at  a  lower  level, 
for  the  untorn  outer  portion  prevents  the  shaft  from  sinking  unless  the 
head  correspondingly  rises. 

Symptoms.  The  flattening  of  the  outer  portion  of  the  shoulder,  the 
prominence  of  the  acromion,  and  the  abduction  of  the  elbow  are  all 
more  marked  than  in  the  subcoracoid  dislocation  ;  and  the  axis  of  the 
arm  prolonged  by  the  eye  in  front  passes  below  and  to  the  inner  side 
of  the  glenoid  cavity.  Measured  in  partial  abduction  from  the  acro- 
mion to  the  elbow,  the  arm  appears  longer  than  its  fellow,  and  this 
elongation  may  not  give  place  in  complete  horizontal  abduction  to  as 
much  shortening  as  is  found  in  the  subcoracoid  form.  The  head  of 
the  humerus  can  be  plainly  felt  in  the  axilla,  and  is  separated  from  the 
coracoid  process  by  an  interval  of  from  half  an  inch  to  an  inch. 

The  differential  diagnosis  from  subcoracoid  dislocation  is  made  by 
recognition  of  the  position  of  the  head  below  the  glenoid  fossa ;  the 
corroborative  symptoms  are  the  more  marked  flattening  of  the  deltoid 
and  its  angle  with  the  arm  and  the  wider  abduction  of  the  elbow. 

Treatment.  Theoretically,  the  position  of  the  head  below  the  glenoid 
fossa  suggests  that  traction  should  be  made  upward  and  outward,  the 
elbow  being  raised  above  the  shoulder,  and  this  plan  is  generally  recom- 
mended and  usually  successful.  The  objection  to  it  is  the  added  risk 
of  doing  injury  to  the  bloodvessels  in  the:axilla  by  overstretching  them 
around  the  head  of  the  humerus,  as  explained  in  the  preceding  chapter. 

It  is  prudent,  therefore,  that  a  trial  should  first  be  made  of  the 
method  of  direct  reposition  (p.  629),  and,  that  failing,  of  traction  in 
the  direction  of  the  arm  as  found,  or  with  a  little  more  abduction,  fol- 
lowed by  adduction  while  pressure  outward  and  upward  is  made  upon 
the  head  of  the  bone,  or  with  the  fist  in  the  axilla.  The  reader  is 
referred  to  the  preceding  chapter  for  the  details. 

2.  Luxatio  Erecta. 

This  striking  dislocation,  first  described  by  Middeldorpf,  and  his 
pupil  Scharm  ^  who  reported  the  former's  two  cases,  is  characterized 
by  the  marked  elevation  of  the  arm,  the  forearm  usually  resting  on 
the  top  of  the  head,  a  position  from  which  it  cannot  be  lowered  with- 
out causing  great  pain,  and  by  the  prominence  of  the  head  low  in  the 
axilla.  Besides  Middeldorpf 's  two  cases  I  have  met  with  the  descrip- 
tion or  mention  of  six  others  by  Busch,^  Panas,^  Lange,*  Alberti,^ 
Hannson,**   and    Judd,^   and    a   reference    by   Bardenheuer,^   without 

'  Middeldorpf:  Cliniqne  Europeenne,  1859,  vol.  ii.,  and  Scharm,  De  nova  humeri  luxa- 
tionis  specie.     Di.ssert.  Inaug.  Breslau,  1859;  quoted  by  Alberti,  vide  infra. 
»  Busch  :  Archiv  fiir  klin.  Chir.,  1863,  vol.  iv.  p.  30. 
'  Pauas  :  Diet,  de  Med.  et  Chir.  pratiques,  art.  Epaule,  p.  405. 
*  Lange :  New  York  Medical  Record,  1879,  vol.  xvi.  p.  400. 

5  Alberti :  Deutsche  Zeitschrift  fiir  Chir.,  1884,  vol.  xx.  p.  475. 

6  HaiinsoTi :  Centrabl.  fiir  Chir.,  1892.  p.  18. 

'  Judd  :  New  York  Medical  Journal,  October  19,  189.5.     ^  Bardenheuer  :  Loc.  cit.,  p.  303. 


DOWNWARD  DISLOCATIONS  OF  THE  SHOULDER.  657 

details,  to  a  case  reported  by  Bertin  and  two  eases  reported  by  Meyer. 
Three  cases  have  been  admitted  at  the  Hudson  Street  Hospital,  but  I 
saw  only  one  of  them. 

The  only  opportunity  for  direct  examination  of  the  parts  was  fur- 
nislied  in  one  of  Middeldorpf's  cases ;  the  patient's  right  arm  was 
caught  in  some  machinery  and  he  was  whirled  around,  receiving  in 
addition  to  the  dislocation  a  w^ound  of  the  deltoid  ;  he  died  of  pyaemia. 
The  greater  tuberosity  had  been  torn  off,  remaining  attached  to  its 
three  muscles,  and  the  acromion  was  broken.  Scharm  produced  the 
dislocation  five  times  upon  the  cadaver ;  in  every  case  the  supraspina- 
tus  and  infraspinatus  muscles  were  torn  away,  and  in  two  there  was 
partial  rupture  of  the  subscapidaris  and  pectoralis  major.  The  main 
bloodvessels  and  nerves  were  uninjured.  My  only  knowledge  of  Mid- 
deldorpf's  cases  and  Scharm's  experiments  comes  from  the  brief  men- 
tion made  of  them  by  Alberti. 

Lange's  case,  in  which  the  dislocation  was  intracoracoid  rather  than 
subglenoid,  differs  also  from  the  others  in  the  less  complete  elevation 
of  the  arm.  Bardenheuer  ^  says  that  in  his  experience,  covering  about 
four  hundred  cases  of  dislocation  of  the  shoulder,  he  had  never  encoun- 
tered a  pure  luxatio  erecta,  but  he  had  met  with  two  cases  in  which  the 
arm  was  abducted  beyond  a  right  angle  with  the  body.  Lange's  case 
might  properly  be  regarded  as  an  exceptional  form  of  intracoracoid  dis- 
location intermediate  between  the  usual  form  and  the  luxatio  erecta. 

The  mechanism  appears  to  have  been  forcible  and  extreme  elevation 
of  the  arm,  combined  in  one  case  ( Albert!' s)  with  a  blow  upon  the 
arm  from  above  downward,  and  the  elevated  position  after  dislocation 
was  plainly  due  to  the  tension  of  the  anterior  soft  parts  created  by  the 
shifting  of  the  centre  of  motion  to  a  point  so  far  below  the  glenoid 
cavity.  In  one  of  Meyer's  cases  mentioned  by  Bardenheuer,  a  woman 
sixty-two  years  old,  it  is  said  that  the  dislocation  occurred  during  an 
epileptic  fit.  It  is  stated  also  that  in  one  of  the  cases  "paralysis  of 
the  brachial  plexus"  persisted  after  reduction. 

The  method  of  reduction  adopted  in  all  the  cases  was  clearly  the 
proper  one,  not  only  because  it  succeeded  but  also  because  it  corre- 
sponded to  the  anatomical  indications.  Traction  in  the  direction 
assumed  by  the  arm  drew  the  head  directly  back  toward  its  socket  by 
the  route  along  which  it  had  escaped. 

3.  Subtricipital  Dislocation  (?). 

Our  knowledge  of  this  very  rare,  and  even  questionable,  form  is 
limited  to  a  single  doubtful  case  observed  clinically  by  Farabeuf,^  and 
to  subsequent  experiments  made  by  him  upon  the  cadaver.  As  the 
luxatio  erecta  is  produced  from  a  subglenoid  by  exaggerating  the 
descent  of  the  head  of  the  humerus,  so  the  subtricipital  is  said  to  be 
produced  from  the  erecta  by  a  consecutive  displacement  of  the  head 
upward  and  backward,  at  first  underneath  and  then  behind  and  above 

'  Bardenheuer  :  Loc.  cit.,  p.  303. 

2  Fardbeuf :  Bull,  de  la  Soc.  de  Chir.,  1879,  p.  778,  and  1885,  p., 396. 


658  DISLOCATIONS. 

the  long  tendon  of  the  triceps,  a  displacement  effected  by  the  descent 
of  the  elbow  in  front. 

The  case  was  that  of  a  sailor  who  injured  his  shoulder  while  at  sea ; 
five  weeks  later  he  lauded  at  Bordeaux,  and,  attempts  made  there  to 
reduce  having  failed,  he  went  to  Paris.  The  arm  was  abducted  and 
carried  forward,  and  the  head  of  the  humerus  rested  on  the  back  of 
the  scapula  two  finger-breadths  below  the  angle  of  the  acromion. 
Reduction  was  not  obtained. 

In  his  experiments  upon  the  cadaver  Farabeuf  found  that  after  rais- 
ing the  arm  forcibly  and  thus  tearing  the  capsule  at  its  lower  part  he 
could,  by  a  vigorous  push  or  a  blow  upon  the  elbow  with  a  mallet, 
make  the  head  of  the  humerus  descend  several  centimetres  below  the 
glenoid  cavity ;  if  then  the  arm  was  lowered  in  front  the  head  of  the 
bone  moved  backward  and  became  engaged  under  the  tendon,  which 
then  held  the  arm  abducted  and  directed  forward  and  more  or  less 
rotated  inward. 

Farabeuf 's  case  is  apparently  the  one  mentioned  by  Poinsot^  as 
Sebilleau's  and  as  having  been  examined  by  himself  in  1881.  The 
limb  was  then  in  slight  abduction  and  inward  rotation,  the  elbow  and 
fingers  flexed ;  movements  at  the  shoulder  were  almost  completely 
lost.  The  case  is  described  by  Poinsot  as  one  of  dislocation  backward 
(subacromial  or  subspinous),  and  no  reference  is  made  by  him  to 
Farabeuf 's  opinion  concerning  it,  although  he  is  named  among  the 
surgeons  who  had  examined  it. 

Farabeuf  maintains  that  two  very  similar  cases  observed  by  Richet 
and  Bottey  and  named  by  the  former  retro-axillary  (see  Posterior  Dis- 
locations) were  really  examples  of  this  variety  described  by  him.  It 
seems  more  probable  that  Farabeuf  was  misled  by  his  experiments 
and  that  the  three  cases  were  merely  low  posterior  dislocations. 

Supposing  such  a  case  to  exist,  reduction  should  be  made  by  first 
transforming  the  dislocation  into  a  luxatio  erecta  by  raising  the  elbow 
with  traction  to  the  side  of  the  head,  so  as  to  bring  the  bone  from 
beneath  the  triceps,  and  then  i^educing  by  direct  traction  upward. 

POSTERIOR  DISLOCATIONS. 
Subacromial  and.  Subspinous. 

Dislocations  backward  are  divided  into  two  classes,  the  subacromial 
and  the  subspinous,  according  as  the  head  lies  under  the  projecting 
outer  border  of  the  acromion  or  further  back  below  the  spine  of  the 
scapula,  respectively.  A  variety  of  the  subacromial,  to  which  the 
name  retro-axillary  has  been  given,  has  been  recently  observed  and 
described  by  Richet  and  Bottey. 

Although  I  think  this  division  into  two  groups  is  cpiite  generally 
accepted  by  the  profession,  yet  Engli.sh  and  American  systematic 
writers  upon  the  sul)ject  have,  as  a  rule,  refused  to  adopt  it,  giving  as 
a  reason  therefor  the  fact  that  the  two  differ  only  in  an  unimportant 

1  Poinsot :  Translatiou  of  Hamilton's  Fractures  and  Dislocations,  p.  867. 


POSTERIOR   DISLOCATWNS  OF  THE  SHOULDER.  659 

feature,  the  degree  of  the  displacement,  and  they  apply  the  term  sub- 
spinous  to  all.  Flower^  justifies  the  choice  of  this  name  in  preference 
to  subacromial  on  the  ground  that  tiie  latter  does  not  express  any 
change  from  the  normal  situation  of  the  head  of  the  humerus  under 
the  acromion.  On  the  other  hand,  it  may  be  fairly  urged  that,  as  in 
tlie  great  majority  of  cases  the  head  is  not  displaced  so  far  as  to  the 
spine  of  the  scapula,  the  term  subspinous  is  misleading  and  improper. 
I  have  preferred,  in  accordance  with  what  I  believe  to  be  the  general 
practice  of  the  profession,  to  retain  both  terms  with  the  distinction 
between  them  established  by  Malgaigne.  Of  the  two  groups  the  sub- 
acromial is  much  the  more  frequent,  the  subspinous  being  very  rare. 

According  to  Malgaigne  the  earliest  recorded  mention  of  this  dislo- 
cation was  in  1834,  and  wlieu  he  wrote,  in  1855,  he  could  collect  only 
34  cases,  of  which  he  himself  observed  3.  A  very  considerable  num- 
ber of  cases  have  been  recorded  since  that  time  (I  found  7  in  the  Index 
Jledicus  for  the  years  1878  to  1882),  and  Panas's  opinion  that  many 
escape  recognition,  by  being  mistaken  for  a  sprain  or  an  articular  frac- 
ture, seems  fairly  justified,  for  not  only  are  the  diagnostic-  symptoms 
sometimes  very  obscure,  but  Nelaton  said  that  he  had  within  a  short 
period  of  time  seen  three  cases  that  had  passed  unrecognized  by  sur- 
geons of  merit.  EUerbrook^  reports  seven  traumatic  cases  among  172 
dislocations  of  the  shoulder  treated  in  the  G5ttingen  Poliklinik.  In 
Malgaigne's  statistics  26  were  men  and  5  women ;  and  in  rather  more 
than  a  quarter  of  them  the  cause  was  muscular  action.  Bardenheuer  saw 
one  in  which  both  shoulders  had  been  dislocated  by  a  fall  forward  upon 
the  elbows.     (See,  also.  Chapter  XLIV.,  Birth  Dislocations.) 

Experiment  upon  the  cadaver  shows  that  the  dislocation  can  be 
readily  produced  by  forcible  internal  rotation  of  the  arm,  by  which 
the  posterior  portion  of  the  capsule  is  torn  and  the  passage  backward 
and  outward  of  the  head  is  made  easy.  In  some  of  the  cases  clinically 
observed  it  is  plain  that  this  has  been  the  mechanism,  and  in  others 
it  has  undoubtedly  aided.  Thus,  Piel,  who  wrote  a  thesis  on  the  sub- 
ject in  1851,  saw  a  woman  in  whom  it  had  been  caused  by  her  husband 
twisting  her  arm  in  a  quarrel.  In  seven  of  Malgaigne's  cases  and  in 
several  that  have  since  been  reported  the  dislocation  occurred  during 
an  epileptic  fit,  presumably  by  internal  rotation  of  the  limb.  In  other 
cases  the  cause  has  been  a  blow  upon  the  front  of  the  shoulder  (twice 
a  blow  with  the  fist),  pressure  upon  the  back  of  the  shoulder  while  the 
elbow  rested  against  the  ground,  an  attempt  to  control  the  patient  in 
convulsions,  once  the  throwing  of  a  stone  by  a  boy  ten  years  old,  and 
frequently  a  fall.  The  anatomical  features  of  the  joint,  the  results  of 
cadaveric  experiment,  and  such  histories  of  cases  as  are  sufficiently 
complete  indicate  that  the  common  mode  of  production  is  pressure 
backward  and  outward  upon  the  head  of  the  humerus,  either  directly 
or  through  the  elbow,  combined  with  adduction  of  the  limb  across  the 
front  of  the  chest  and  internal  rotation.  Such  a  combination  is  most 
frequently  found  in  falls  forward  in  which  the  weight  is  received  upon 

1  Flower:  Holmes's  ^^ystem  of  Siirnrerv,  Am.  ed.,  vol.  i.  p.  875. 

2  Ellerbrook  :   Deutsche  Ztsclift.  fin-  Chir.,  vol.  xcii.  p.  453. 


660  DISLOCATIONS. 

the  adducted  elbow.  One  of  Malgaigne's  cases  is  especially  interesting 
from  this  point  of  view,  as  sho^^dng  the  conditions  of  the  production 
abnost  as  clearly  as  an  experiment.  A  woman  was  trying  to  take 
down  a  box  placed  high  above  her  head,  it  slipped  suddenly  into  her 
extended  hand,  and  the  cUslocation  occurred.  In  other  words,  the  force 
was  exerted  in  a  suitable  direction  upon  an  arm  that  was  elevated, 
adducted,  and  rotated  inward.  And  in  a  case  reported  by  ]MouIlin 
and  Keith^  the  mechanism  is  almost  as  clearly  shown.  A  man  making 
and  missing  a  back-handed  stroke  at  tennis  received  the  dislocation. 
As  I  interpret  it,  the  arm  was  stretched  across  the  chest  and  strongly 
rotated  inward,  and  in  the  effort  the  deltoid  drew  the  head  of  the 
humerus  backward  and  outward. 

In  a  case  observed  by  Tillaux^  the  patient,  a  man  twenty-four  years 
old,  had  his  right  arm  caught  in  some  machinery  and  was  drawn  sev- 
eral times  about  a  revolving  shaft,  receiving  a  subspinous  dislocation, 
and  in  addition  having  the  arm  almost  completely  torn  away  at  its 
middle  by  being  twisted  several  times  upon  itself. 

Autopsies  have  been  made  in  six  recent  cases  in  which  death  was 
caused  by  associated  injuries.  In  Maisonneuve's  case  (the  specimen 
is  pictured  in  Malgaigne's  Atlas,  Plate  XXII.,  figs.  5  and  6)  the 
patient  fell  from  a  height  of  thirty  feet.  The  capsule  was  torn  above, 
below,  and  on  its  outer  side  ;  the  greater  tuberosity  was  torn  off,  broken 
into  two  pieces,  and  drawn  back  below  the  acromio-clavicular  arch  by 
the  suprasjiinatus  and  infraspinatus  muscles  to  which  it  remained 
attached.  The  teres  minor  and  subscapularis  were  still  attached  to  the 
humerus  ;  the  long  tendon  of  the  biceps  had  been  torn  out  of  its  groove. 
The  circumflex  nerve  was  uninjured.  The  head  of  the  humerus  lay 
just  below  the  posterior  angle  of  the  acromion  and  was  not  in  contact 
with  either  the  spine  or  the  neck  of  the  scapula,  but  rested  against  the 
posterior  edge  of  the  glenoid  cavity. 

In  Laugier's^  case  the  subscapularis  and  supraspinatus  were  torn 
from  their  insertions,  and  the  head  of  the  humerus  had  passed,  as  in 
Maisonneuve's  case  also,  between  the  infraspinatus  and  teres  minor 
and  was  covered  only  by  the  deltoid. 

Two  cases  were  reported  by  J5ssel,*  one  a  subacromial,  the  other  a 
subspinous  dislocation.  In  the  first  the  injury,  together  with  a  frac- 
ture of  the  skull,  Avas  caused  by  a  fall  into  a  cellar.  The  head  of  the 
humerus  had  torn  through  the  teres  minor  and  lay  under  the  acromion  ; 
the  limb  was  so  far  rotated  inward  that  the  articular  surface  looked 
directly  outward.  The  supraspinatus  and  infraspinatus  were  unin- 
jured. The  capsule  showed  a  triangular  rent  on  the  outer  side  just 
large  enough  to  let  the  head  through.  The  tendon  of  the  subscapu- 
laris was  still  attached  to  the  humerus,  but  under  it  and  close  by  the 
tendon  of  the  biceps  an  irregular,  movable  piece  of  bone  could  be  felt, 
the  lesser  tuberosity,  the  fracture  by  which  it  was  separated  extending 

1  MouUin  and  Keith:  Lancet,  1904,  vol.  i,  p.  496. 

2  Tillaux:  Anatomie   topographique,    p.   536. 
^  Laugier:  Gaz.  des  Hopitaux,  1S46,  p.  60. 

*  Jossel:  Deutsche  Zeitschrift  fiir  Chir.,  1874,  vol.  iv.  p.  125. 


POSTERIOR  DISLOCATIONS  OF   THE  SHOULDER.  661 

into  the  bicipital  groove;  the  tubercle  was  split  into  two  pieces,  both 
adherent  to  the  tendon. 

In  the  second  case  the  patient  fell  from  a  height  of  two  stories, 
dislocated  the  left  shoulder,  and  sustained  a  compound  fracture  of 
the  thigh;  he  died  on  the  fifth  day.  The  head  of  the  humerus  had 
torn  through  the  teres  minor  and  lay  under  the  spine  of  the  scap- 
ula, separated  from  it  by  the  interposed  infraspinatus  ;  it  was  directed 
backward.  The  long  head  of  the  triceps  was  almost  entirely  torn 
through,  and  a  piece  was  broken  from  the  axillary  border  of  the  scap- 
ula just  below  the  glenoid  fossa.  The  subscapularis  and  the  adjoining 
part  of  the  capsule  were  torn  away  from  the  humerus,  bringing  with 
them  the  lesser  tuberosity,  the  fracture  of  which  was  broader  than  in 
the  preceding  case. 

In  the  remaining  two  cases  the  dislocations  were  subspinous ;  in  one 
of  them,  quoted  by  Malgaigne,^  the  patient,  a  man  sixty-two  years  old, 
fell  backward,  and  the  wheel  of  his  wagon,  which  carried  a  load  of 
three  and  a  half  tons,  passed  obliquely  across  the  right  side  of  his 
chest,  causing  injuries  which  resulted  in  his  death  thirty  hours  later. 
Several  ribs  were  fractured,  as  were  also  the  body  of  the  scapula  and 
the  inner  portion  of  its  spine.  The  deltoid,  pectoralis  major,  teres 
major,  and  teres  minor  were  torn  or  crushed,  and  the  capsule  was 
almost  entirely  detached.  When  the  arm  was  lowered  the  head  of  the 
humerus  lay  below  the  spine  of  the  scapula  in  the  outermost  part  of 
the  subspinous  fossa,  the  lesser  tuberosity  corresponding  to  the  edge 
of  the  glenoid  fossa. 

In  the  other,  reported  by  Collins,^  a  man  sixty  years  old  was  knocked 
down  and  run  over,  sustaining,  in  addition  to  the  dislocation  of  his 
right  shoulder,  fracture  of  several  ribs ;  he  died  in  a  few  days  of  pneu- 
monia. The  capsule  was  torn  on  all  sides ;  the  supraspinatus  and 
subscapularis  were  torn  away  at  their  insertions,  and  the  long  tendon 
of  the  biceps  was  detached  from  the  bicipital  groove.  The  head  of 
the  humerus  lay  between  the  teres  minor  and  the  infraspinatus, 
"  immediately  beneath  the  scapular  spine." 

In  an  operation  for  the  reduction  of  old  dislocation^  the  lesser 
tuberosity  was  found  to  have  been  broken  off. 

The  important  complication  of  fracture  of  the  anatomical  neck  has 
been  reported  in  two  cases,  one  by  Delpech,  the  other  by  Malgaigne ;  * 
in  each  the  cause  was  a  fall  upon  the  shoulder.  In  Delpech's  case  the 
fall  was  due  to  an  apoplexy  which  soon  proved  fatal ;  the  head  had 
passed  entirely  through  a  large  rent  in  the  postero-external  part  of  the 
capsule,  its  fractured  surface  lay  against  the  subspinous  fossa,  and  its 
articular  surface  was  directed  backward  and  covered  by  the  infraspi- 
natus muscle.  The  nuiscular  attachments  to  the  humerus  were  all 
preserved,  and  the  long  tendon  of  the  biceps  was  intact. 

jNIalgaigne's  case  was  not  seen  by  him  until  eleven  months  after  the 

1  Malgaigne:  Loc.  cit.,  p.  541.  According  to  Soyez  (Th^se  de  Paris,  1880,  No.  179)  the 
case  was  treated  by  Denonvilliers,  who  deposited  the  specimen  in  the  Musee  Dupuytren. 
It  is  reported  by  Malgaigne  as  if  he  had  himself  observed  it.  Hence  has  arisen  the  error 
of  supposing  that  they  were  different  cases. 

-  Collins:   Dublin  .Journal  Med.  Sci.,   1879,  vol.  ii,  p.  166. 

3  Engel:  Arch,  fur  klin.  Chir.,  1897,  vol.  Iv,  p.  603. 

*  Soyez:  These  de  Paris,  1880,  No.  179,  p.  28. 


662  DISLOCATIONS. 

receipt  of  the  injury;  the  head  of  the  humerus  could  be  felt  as  an 
immovable,  hemispherical  body,  two  inches  in  diameter,  and  half  an 
inch  below  the  posterior  angle  of  the  acromion.  The  arm  was  short- 
ened half  an  inch,  the  elbow  slightly  abducted  and  not  rotated.  The 
upper  end  of  the  shaft  corresponded  to  the  glenoid  cavity.  The  arm 
was  slightly  movable  ;  the  head  did  not  share  in  its  movements. 

The  results  obtained  by  experiments  upon  the  cadaver  are  in  har- 
mony with  these  post-mortem  records.  In  the  subacromial  variety  the 
head  of  tiie  humerus  is  found  under  the  acromion  looking  backward 
and  inward,  with  its  anatomical  neck  engaged  against  the  posterior 
edge  of  the  glenoid  fossa,  and  the  lesser  tuberosity  lying  on  the  latter. 
The  tendon  of  the  subscapularis  covers  the  anterior  and  inner  part  of  the 
fossa,  and  is  usually  more  or  less  detached  from  its  insertion  upon  the 
humerus.  The  dislocation  can  be  transformed  into  a  subspinous  one 
by  diminishing  the  internal  rotation  sufficiently  to  free  the  lesser  tuber- 
osity, and  then  forcing  the  humerus  backward  toward  the  dorsum  of 
the  scapula,  tearing  the  capsule  more  extensively,  lacerating  the  infra- 
spinatus, increasing  the  separation  of  the  subscapularis,  and  tearing 
off  also  the  supraspinatus  from  its  insertion.  The  dividing  line 
between  the  two  varieties  is  necessarily  an  arbitrary  one,  and  in  some 
cases  it  must  be  difficult  to  determine  to  which  variety  the  case  belongs. 
Malgaigne's  definitions  are  as  follows  :  The  subacromial  is  one  in  which 
the  head  of  the  humerus  lies  under  the  posterior  angle  of  the  acromion  ; 
the  subspinous,  one  in  which  it  has  been  displaced  behind  the  angle  of 
the  acromion  and  lies  under  the  spine  of  the  scapula. 

Symptoms.  The  symptoms  in  recent  cases  are  not  very  marked,  and 
the  characteristic  ones  may  be  masked  by  the  swelling.  In  the  sub- 
acromial variety  the  shoulder  seems  full  behind  and  flattened  in  front. 
The  arm  hangs  by  the  side,  the  elbow  usually  directed  somewhat  for- 
ward, and  is  rotated  inward.  The  coracoid  process  can  be  })lainly  felt, 
and  perhaps  seen  ;  the  acromion  is  prominent  in  front.  The  absence 
of  the  head  of  the  humerus  from  its  socket  is  recognized  by  pressure 
made  in  front,  and  its  presence  behind  and  to  the  outer  side  is  deter- 
mined by  palpation  combined  with  gentle  movements  of  the  limb.  In 
the  older  cases  the  subsidence  of  the  inflammatory  swelling  and  the 
atrophy  of  the  deltoid  consequent  upon  disuse  make  the  deformity 
more  marked.  Voluntary  movements  are  abolished,  and  communicated 
niovements  restricted  and  painful.  Comparative  measurements  have 
not  shown  constant  or  notable  differences  in  length.  In  two  cases  of 
my  own  the  arm  M^as  rigidly  held  close  to  the  side,  and  communicated 
movements  were  extremely  painful.  Reduction  by  traction,  under 
ether,  was  easy,  and  full  use  of  the  limb  was  promptly  regained. 

The  attitude  is  probably  due  to  the  persistence  of  the  anterior 
portion  of  the  capsule,  which  is  noted  in  most  of  the  autopsies  and 
all  tile  experiments  upon  the  cadaver. 

In  the  subs])inous  variety  the  attitude  of  the  arm  in  the  few  reported 
cases  has  not  been  always  the  same  ;  sometimes  the  elbow  has  been 
held  close  to  the  trunk  and  projected  forward  ;  in  Malgaigne's  it  was 
rotated  inward,  but  otherwise  freely  movable,  and  remained  in  such 
position  as  was  given  to  it.     In  Desclaux's  it  was  held  horizontally  in 


POSTERIOR  DISLOCATIONS  OF   THE  SHOULDER.  663 

front  of  the  upper  part  of  the  chest,  and,  as  any  attempt  to  lower  it 
caused  great  pam,  the  patient  sought  to  keep  it  immovable  by  placing 
the  hand  on  the  top  of  his  head.  The  local  symptoms  at  the  shoulder 
are  much  the  same  as  those  in  the  subacromial  variety ;  there  is  the 
same  prominence  of  the  coracoid  process  and  acromion,  the  flattening 
of  the  front  and  the  fulness  of  the  back  of  the  shoulder,  the  absence 
of  the  head  of  the  humerus  from  its  socket  and  its  presence  behind, 
in  this  case,  of  coarse,  further  back  behind  the  angle  of  the  acromion 
and  below  the  spine  of  the  scapula. 

Richet,  in  1882,  treated  a  case  which  differed  widely  in  one  respect 
from  both  the  subacromial  and  subspinous  forms,  namely,  in  that  the 
head  of  the  humerus,  instead  of  being  in  contact  with  the  acromion,  lay 
at  a  distance  of  two  finger-breadths  below  it,  close  behind  the  glenoid 
fossa.  He  considered  it  a  new  variety,  representing  the  first  stage  in 
the  production  of  the  subacromial,  and  gave  it  the  name  of  7'etro- 
axillary.  The  case  was  published  by  Bottey,  his  interne,  in  the  Pro- 
gres  Medical,  August  5,  1882,  and  subsequently  republished  with 
another  also  observed  by  Bottey  in  his  graduating  thesis.^  The  two 
cases  resembled  each  other  very  closely  ;  the  patients  were  women,  aged 
seventy-eight  and  seventy-two  years,  respectively,  and  the  injury  was 
caused  in  each  case  by  a  fall  upon  the  shoulder ;  in  one,  while  walking 
in  the  street ;  in  the  other,  from  her  bed,  against  a  chair.  The  elbow 
was  directed  forward  and  held  near  the  body,  and  in  the  second  case 
the  patient  supported  the  limb  with  the  other  hand  because  of  the  pain 
its  weight  caused.  As  both  patients  were  thin  and  there  was  no  swell- 
ing, the  head  of  the  humerus  could  be  very  distinctly  felt  behind  the 
posterior  edge  of  the  glenoid  fossa  and  slightly  separated  from  it,  and 
distant  from  the  acromion  by  two  good  finger-breadths.  External 
rotation  of  the  limb  was  marked.  Reduction  was  easily  effected  by 
direct  impulsion,  and  both  patients  recovered  promptly. 

The  position  of  the  head  may  be  explained  by  assuming  that  the 
rent  in  the  capsule  was  exceptionally  low,  and  did  not  extend  upward 
along  the  posterior  border  of  the  glenoid  fossa. 

Prognosis.  The  prognosis  is  favorable  as  regards  the  probability  of 
effecting  reduction  (in  two  or  three  cases  the  head  has  been  unexpect- 
edly returned  to  its  place  by  the  manipulations  employed  to  make  the 
diagnosis),  but  it  is  very  unfavorable  if  the  dislocation  is  left  unre- 
duced, for  then  the  range  of  motion  is  usually  very  slight.  In  a  case 
reported  by  Sir  Astley  Cooper,  in  which  the  dislocation  immediately 
recurred  after  every  reduction  and  was  finally  abandoned,  the  patient 
survived  seven  years,  but  remained  unable  to  use  or  even  move  the 
arm  to  any  extent.  The  tendency  to  recurrence  was  attributed  to  the 
separation  of  the  tendon  of  the  subscapularis  from  the  humerus,  and 
to  the  consequent  lack  of  support  on  that  side.  The  same  tendency 
has  been  noted  in  other  cases.  Bardcnheuer  says  it  existed  in  three  of 
his  four,  and  that  in  two  of  them  movements  of  tiie  joint  gave  rise  to 
crepitus.  In  some  of  the  cases  the  full  use  of  the  limb  has  been 
regained  in  a  very  short  time  after  reduction,  a  week  or  ten  days. 

1  Bottey:  Deux  cas  de  luxation  do  I'cpaulc  cii  arri^re  et  en  has  (luxation  rctro-axillaire). 
Th^se  de  Paris,  1884,  No.  13. 

46 


664  DISLOCATIONS. 

Diagnosis.  The  diagnosis,  as  has  been  already  said,  may  be  difficult, 
especially  if  there  is  much  swelling.  The  injury  appears  to  have  been 
not  infrequently  mistaken  for  a  sprain  or  a  contusion.  The  attitude 
and  the  direction  of  the  axis  of  the  arm,  except  in  the  rare  subspinous 
cases,  are  not  sufficiently  characteristic  even  to  suggest  the  existence  of 
the  injury,  and  unless  the  examination  is  systematically  made  with  a 
view  to  determine  the  position  of  the  head  of  the  humerus,  as  should 
be  done  in  all  cases  of  injury  in  this  region,  the  dislocation  may  be 
overlooked.  If  the  head  of  the  bone  can  be  felt  and  its  relations  to 
the  acromion  determined,  no  doubt  should  remain. 

Treatment.  Reduction  has  been  easily  effected  in  both  recent  and 
old  cases  by  a  variety  of  methods.  The  one  that  has  furnished  the 
largest  number  of  successes  is  direct  pressure  from  behind  forward 
upon  the  head  of  the  humerus  with  counter-pressure  upon  the  front  of 
the  acromion,  usually  associated  with  traction  upon  the  arm,  or  with 
gentle  movements  of  the  limb  in  various  directions.  Sedillot  success- 
fully reduced  a  dislocation  that  had  existed  for  a  year  and  fifteen  days. 

The  position  and  relations  of  the  untorn  portion  of  the  capsule  indi- 
cate that  the  best  manipulation  would  be  elevation  of  the  elbow  in 
front  and  toward  the  median  line,  combined  with  inward  rotation  to 
relax  the  anterior  portion  of  the  capsule,  and  followed  by  direct  pro- 
pulsion of  the  head  from  behind  toward  its  socket,  or  by  traction  in 
the  direction  of  the  long  axis  of  the  arm.  Simple  external  rotation 
might  succeed  when  the  articular  surface  of  the  head  rests  against  the 
edge  of  the  glenoid  cavity,  as  it  sometimes  does,  for  by  making  the 
front  of  the  capsule  tense  it  would  rotate  the  posterior  surface  of  the 
bone  inward  and  forward,  but  the  success  of  this  manipulation  might 
easily  be  prevented  by  the  increased  friction  between  the  two  bones. 

UPWARD   DISLOCATIONS. 
Supraglenoid,  Supracoracoid. 

The  possibility  of  the  occurrence  of  this  rare  form  of  dislocation, 
which  has  often  been  denied,  has  at  last  been  established  by  the  clin- 
ical observation  of  several  cases  and  the  post-mortem  examination  of 
two. 

The  first  alleged  case  was  reported  by  Laugier^  in  1834  as  an  incom- 
plete dislocation  upward  ;  the  second  was  by  Malgaigne.^  In  1858 
Bourget  submitted  to  the  Societe  de  Chirurgie  a  paper  upon  the  subject 
containing  the  accounts  of  three  cases  observed  by  himself,  two  of 
which  he  diagnosticated  as  complete  dislocations,  and  one  as  incomplete, 
and  reproducing  the  cases  of  Laugier,  Malgaigne,  and  Avrard.  Upon 
this  paper  Morel-La  valine  ^  made  an  elaborate  report,  denying  the  cor- 
rectness of  the  diagnosis  in  all  the  reported  cases  and  attributing  the 
observed  deformity  to  a  prolonged  arthritis,  and  he  supported  this 

1  Laugier:  Arch.  gen.  deMed.,  1834,  vol.  x.  p.  65;  also  in  Dictionnaire  en  30  vols.,  vol. 
xiii.  p.  81. 

2  Malgaigne  :  Rev.  medico-chirurg..  1849,  vol.  v.  p.  30,  and  Luxations,  p.  530. 
»  Morel-Lavallee :  Bull,  de  la  Soc.  de  Chir.,  1858,  vol.  viii.  p.  490, 


UPWARD  DISLOCATIONS  OF  THE  SHOULDER.  665 

opinion  by  quoting  the  case  of  Sotlen/  in  which  the  symptoms  Avere 
the  same  as  in  Laiigier's  case,  but  the  autopsy,  five  months  later, 
showed  the  changes  of  a  dry  arthritis.  He  seems  to  have  attached  no 
importance  to  the  dislocation  inward  of  the  long  tendon  of  the  biceps. 
The  alleged  cases  on  record  are  Malgaigne's,  two  of  Bourget,  and 
those  of  Chassaignac,"  Holmes,^  Prescott  Hewett  (quoted  by  Holmes), 
Denonvilliers,*  Albert,^  Busch,"  Verneuil,''  Le  Dentu,  Tuffier,*^  Rob- 
son,^  and  Streeter,^*^  fourteen  in  all,  in  one  of  which  (Albert)  both 
shoulders  were  dislocated  in  the  same  manner  and  at  the  same  time. 

The  cases  that  furnished  autopsies  are  Holmes's,  Albert's,  and  Tuf- 
fier's.  Holmes's  patient  was  a  man  fifty  years  old,  who  had  fallen 
from  a  height  of  about  thirty  feet,  striking  upon  his  head,  the  left  side 
of  his  chest,  and  left  elbow,  and  receiving  in  addition  to  the  dislocation 
in  question  a  compound  dislocation  of  the  radius  and  a  comminuted 
fracture  of  the  upper  portion  of  the  ulna  of  the  same  side.  The  head 
of  the  humerus  formed  a  large  prominence  in  front  of  the  outer  part 
of  the  clavicle ;  movements  of  the  arm  gave  rise  to  crepitus.  No 
attempt  to  reduce  was  made,  and  the  patient  died  on  the  fifteenth  day. 

At  the  autopsy  the  head  of  the  humerus  was  found  immediately 
under  the  skin,  having  passed  through  the  deltoid  near  its  inner  ante- 
rior margin  ;  its  articular  surface  was  entirely  above  the  glenoid  fossa 
and  rested  upon  the  stump  left  by  fracture  of  the  coracoid  process 
near  its  base.  The  coracoid  process  lay  on  its  inner,  the  acromion  on 
its  outer  side  and  somewhat  posteriorly  ;  the  coraco-acromial  ligament 
appears  to  have  been  in  part  torn.  The  subscapularis  was  intact,  but 
the  muscles  attached  to  the  greater  tuberosity  were  torn  through, 
except  a  part  of  the  teres  minor.  The  long  tendon  of  the  biceps  lay 
below  the  head  on  its  outer  side ;  it  was  still  attached  to  the  upper 
margin  of  the  glenoid  fossa,  but  some  of  its  inner  fibres  had  been 
broken  away  from  the  muscle.  The  capsule  was  torn  at  its  upper  and 
inner  part. 

Albert's  case  was  first  seen  by  him  several  years  after  the  injury  was 
received.  The  patient  had  dislocated  both  shoulders  by  holding  on  to 
the  reins  of  a  pair  of  runaway  horses  and  being  drawn  along  the 
ground.  The  deformity  was  more  marked  on  the  left  than  on  the 
right  side,  and  there  consisted  of  a  marked  rounded  prominence  on 
the  front  and  upper  part  of  the  shoulder.  Both  arms  hung  close  by 
the  side,  the  axis  being  directed  obliquely  from  below  upward  and  for- 
ward in  front  of  the  glenoid  fossa.  The  prominence  formed  by  the 
head  of  the  humerus  was  situated  in  front  of  the  acromion,  rising 
about  two  centimetres  above  its  upper  surface,  and  this  elevation  could 
be  increased  by  pressing  the  elbow  upAvard  ;  the  arms  were  so  far  rotated 

'  Soden  :  Medico-Chirurgical  Transactions,  vol.  xxiv.  p.  212. 

^  Chassaignac :  Bull,  de  la  Sue.  de  Chir.,  1858,  vol.  viii.  p.  472. 

'  Holmes  :  Medico-Cliirurgical  Transactions,  18.58,  vol.  xli.  p.  447. 

*  Denonvilliers,  in  Pan  as :  Diet,  de  Med.  et  Chir.  pratiques,  art.  Epaule,  t).  469. 

5  Albert:  Chirurgie,  2d  ed.,  1881,  vol.  ii.  p.  287;  also  in  Wiener  med.   Bliitter,  1879, 
p.  453. 

6  Buseh:  Arch.fur  klin.  Chir.,  1876,  vol.  xix.  p.  400. 
'  Verneuil  in  Pellier  :  These  de  Paris,  1878. 

«  Tuffier  :  Bull,  de  la  Soc.  Anat.,  1886.  p.  292. 
^  Robsou  :  Annals  of  Surgery,  1888,  p.  175. 
1"  Streeter  :  Medical  Record,  February  26,  1887, 


666 


DISLOCATIONS. 


Ftg.  403. 


Supraglenoid     dislo- 
cation.   (Albekt.) 


outward  that  the  transverse  diameter  of  the  lower  end  of  the  humerus 
coincided  with  the  transverse  axis  of  the  trunk.  The  outer  deltoid 
region  was  not  noticeably  flattened,  but  posteriorly  the  fibres  of  that 
muscle  were  greatly  relaxed  and  the  posterior  edge  of  the  glenoid  fossa 
could  be  distinctly  felt  through  them.  The  point 
of  the  finger  could  be  pressed  in  between  the  head 
and  the  coracoid  process.  Slight  voluntary  rotation 
and  movement  of  the  elbow  forward  and  backward 
were  possible ;  very  slight  passive  abduction.  The  left 
elbow  could  be  flexed  only  to  a  right  angle,  further 
flexion  being  arrested  by  the  triceps.  On  the  right 
side  the  deformity  was  the  same  in  character,  but 
less  in  degree,  and  there  was  the  same  limitation  of 
motion.  If  pressure  was  made  upon  the  elbow  di- 
rectly upward  the  movement  could  be  distinctly  felt 
to  be  arrested  by  bony  contact,  and  this  demonstrably 
occurred  between  the  head  of  the  humerus  and  the 
clavicle,  but  if  the  elbow  was  first  carried  back- 
ward the  head  could  then  be  pushed  up  higher. 

At  the  autopsy  the  capsule  was  found  attached 
throughout  to  the  anatomical  neck  of  the  humerus 
and  adherent  also  to  the  upper  part  of  its  articular 
surface ;  thence  it  extended  without  interruption  to  the  margin  of 
the  glenoid  fossa,  but  its  cavity  was  considerably  enlarged.  The 
coraco-acromial  and  coraco-clavicular  ligaments  were  uninjured.  The 
upper  third  of  the  head  of  the  humerus  lay  above  the  level  of  the 
coraco-acromial  ligament,  and  this  overlapping  could  easily  be  in- 
creased to  half  the  head.  The  glenoid  fossa  was  filled  with  a  thick 
layer  of  fibrous  tissue. 

In  the  fuller  account  given  in  the  Wiener  medic inisehe  Blatter,  1879, 
p.  453,  quoted  by  Poinsot,  it  is  said  that  the  long  tendon  of  the  biceps 
on  the  left  side  was  ruptured  and  its  end  adherent  to  the  bone  in  the 
bicipital  groove,  and  that  an  osteophyte  an  inch  long  had  grown  from 
the  base  of  the  coracoid  process. 

Tuffier's  specimen  was  found  in  the  dissecting-room.  The  acromion 
was  broken  ofi^  near  its  base  and  turned  up  and  out ;  the  head  of  the 
humerus  was  in  direct  contact  with  the  acromion  and  coracoid,  and 
the  joint  showed  old  changes  of  dry  arthritis,  including  ossification  of 
the  long  head  of  the  triceps. 

To  these  may  be  added  Robson's  observations  made  during  an  arth- 
rotomy.  His  patient  was  a  boy  sixteen  years  old  who  had  received 
his  injury  six  weeks  earlier  by  the  forcible  dragging  of  his  right  arm 
upward  and  backward.  The  description  of  the  symptoms  is  not  very 
clear,  but  the  head  of  the  humerus  "  lay  about  a  finger-breadth  in 
front  of  the  right  acromion  and  immediately  to  the  outer  side  of  the 
coracoid  process."  Motion  of  the  arm  was  limited  in  every  direction 
except  backward.  The  bone  was  exposed  by  a  curved  incision  on  the 
outer  side  of  the  shoulder,  and  "  it  was  then  discovered  that  in  addi- 
tion to  the  dislocation  of  the  head  of  the  humerus  there  was  a  longi- 
tudinal fracture  separating  the  greater  tuberosity  from  the  head  and 


UPWARD  DISLOCATIONS  OF  THE  SHOULDER. 


m: 


extending  down  the  shaft  for  some  distance  beyond  the  line  of  incision. 
.  .  .  Reduction  could  not  be  effected  in  consequence  of  the  glenoid 
fossa  being  filled  with  callus  and  plastic  material  thrown  out  around 
the  fracture." 

The  other  cases  are  as  follows  : 

Malgaigne.  A  man  sixty  years  old  was  thrown  irom  a  wagon, 
striking  upon  his  shoulder  while  his  arm  was  held  close  to  his  side. 
There  was  much  pain  and  he  was  unable  to  move  the  limb.  A  "  bone- 
setter  "  handled  him  roughly  and  sent  him  away  with  his  arm  in  a 
sling.  Two  and  a  half  months  later  he  consulted  Malgaigne.  The 
head  of  the  humerus  was  dislocated  upward  and  forward  above  the 
coracoid  process,  reaching  the  under  surface  of  the  clavicle,  and  stretch- 
ing the  overlying  deltoid  so  that  on  perforation  with  a  pin  the  latter 
proved  to  be  only  eight  millimetres  in  thickness ;  shortening  one-fifth 
of  an  inch.  Traction  to  the  extent  of  more  than  four  hundred  pounds, 
combined  with  pressure  upon  the  head  downward,  outward,  and  back- 
ward and  counter-pressure  on  the  acromion,  failed  to  effect  reduction, 
although  it  made  the  head  so  movable  that  it  could  be  drawn  down  a 
finger-breadth  below  the  clavicle.  Malgaigne  meditated  division  of 
the  coraco-acromial  ligament,  which  seemed  to  be  the  obstacle,  but 
refrained. 

Bourget's  cases  resembled  Malgaigne's  closely. 

Busch.  (Fig.  404.)  A  horse  reared  and  struck  the  patient,  who 
was  holding  him  by  the  bridle,  upon  the  inner  and  anterior  part  of 
the  shoulder  with  his  hoof.  The  head  of  the  humerus  was  displaced 
upward  and  forward,  the  deformity  closely 
resembling  that  in  Malgaigne's  case  ;  the 
infraclavicular  fossa  was  deepened,  the  arm 
hung  close  by  the  side,  the  posterior  deltoid 
region  was  hollowed,  the  coracoid  process 
could  not  be  felt  in  its  place.  Reduction 
failed. 

Denonvilliers.  A  man  fell  upon  his  arm, 
but  was  unable  to  give  the  details  of  the 
fall.  The  limb  hung  by  the  side  and  was 
strongly  rotated  outward,  Ecchymosis,  pain, 
loss  of  function.  The  head  of  the  humerus 
projected  forward  and  upward  between  the 
coracoid  and  the  acromion  and  in  front  of 
the  clavicle.  Oblique  traction,  combined 
with  a  slight  movement  of  leverage,  effected 
reduction. 

Chassaignac.  A  man  fell  from  the  third 
story  of  a  building.  The  head  of  the  hu- 
merus projected  directly  outward  and  ex- 
tended above  the  coraco-acromial  ligament. 

Movements  of  the  elbow  forward  were  impossible,  backward  they  were 
more  free  than  normal.     The  dislo(>ation  was  easily  reduced  by  exag- 
gerated elevation  of  the  arm,  but  recurred  when  the  arm  was  lowered. 
Hewett.     The  patient  was  a  middle-aged  woman;  the  head  of  the 


Fig.  404. 


Supraglenoid  dislocation :  Busch's 
case.  (Bardenheuer.) 


66g  DISLOCATIONS. 

humerus  lay  on  the  upper  and  inner  side  of  the  glenoid  cavity  ;  there 
was  distinct  crepitus  which  ceased  after  reduction  had  been  made  by 
traction  with  the  heel  in  the  axilla.  Apparently  the  patient  made  a 
complete  recovery. 

Streeter.  '"A  man  of  middle  age  fell  down  stairs,  striking  on  his 
elbow.  The  coracoid  process  was  evidently  fractured,  and  the  articular 
head  of  the  humerus  was  plainly  felt  above  the  clavicle,  the  patient 
being  very  thin.  At  the  present  time  he  is  making  good  progress 
toward  recovery." 

Fracture  of  the  coracoid  progress  existed  in  Holmes's  and  Streeter's 
cases,  and  possibly  also  in  Hewett's  and  Busch's. 

Rupture  or  displacement  of  the  long  tendon  of  the  biceps  must 
occur,  and  rupture  of  the  muscles  attached  to  the  greater  tuberosity 
is  noted  by  Holmes;  it  seems  not  unlikely  that  the  impossibility  of 
reduction  in  several  of  the  cases  was  due  to  the  interposition  of  the 
tendon  of  the  biceps  or  the  stump  of  the  supraspinatus. 

The  mode  of  production  cannot  be  determined  with  an  approach  to 
precision  except  in  the  cases  of  Holmes  and  Streeter,  in  both  of  which 
the  arm  was  driven  upward  by  a  blow  upon  the  elbow.  Tuflfier's  frac- 
ture of  the  acromion  suggests  a  similar  cause. 

Panas's  experiments  upon  the  cadaver  show  that  if  the  arm  is  strongly 
rotated  outward  while  held  close  to  the  body,  and  then  pressed  bodily 
upward  and  forward,  the  capsule  will  tear  at  its  upper  part  and  the 
dislocation  will  be  produced  without  fracture  of  the  coracoid  process, 
the  head  of  the  humerus  rising  not  more  than  one  centimetre  above  its 
normal  position. 

The  symptoms  consist  in  the  presence  of  the  head  of  the  humerus 
in  the  interval  between  the  coracoid  process  and  the  acromion  above 
its  proper  level.  The  coracoid  process  can  be  felt  with  difficulty, 
if  at  all.  Usually  voluntary  movements  are  almost  or  quite  impos- 
sible, and  passive  movements  greatly  restricted,  and  this  restriction 
exists  in  old  as  well  as  in  recent  cases. 

In  three  cases  seen  while  the  injury  was  recent,  Denonvilliers,  Chas- 
saignac,  and  Hewett,  reduction  was  easily  eifected  by  traction  in  two 
and  by  elevation  of  the  elbow  in  one,  but  the  dislocation  recurred  in 
the  latter ;  Verneuil  reduced  on  the  thirty -sixth  day  by  traction  aided 
by  anaesthesia.  In  Holmes's  case  the  associated  injuries  were  so  severe 
that  reduction,  for  which  the  aid  of  chloroform  was  thought  to  be 
necessary,  was  not  attempted.  Malgaigne,  Bourget,  and  Busch  failed, 
the  duration  of  the  dislocation  at  the  time  of  the  attempt  being  two 
and  a  half,  six,  and  five  months  respectively.  The  details  of  Boui'get's 
second  case  are  not  given,  and  the  result  in  Le  Dentu's  I  do  not  know. 
In  Albert's  the  dislocation  had  existed  for  many  years,  and  no  mention 
is  made  of  any  attempt  to  reduce.  In  Streeter's  reduction  seems  to 
have  been  made.  The  persistent  displacement  in  Tuffier's  cannot  be 
accounted  for  except  by  supposing  that  the  arm  was  too  well  supported 
in  a  sling  while  the  injury  was  recent. 


CHAPTER   XLIV. 

DISLOCATIONS  OF   THE  SHOULDER.— (Continued.) 

Associated  Injuries  and  Complications — Prognosis — Habitual  Dislocations — Old 
Dislocations — Congenital  and  Pathological  Dislocations. 

Associated  Injuries  and  Complications. 

The  complications  which  may  coexist  with  a  dislocation  have  been 
described  in  Chapter  XXIX.,  and  will  therefore  be  treated  but  briefly 
here,  and  mainly  with  the  view  of  adding  some  details  to  the  account 
already  given.  In  like  manner  the  accidents  which  may  be  caused  by 
attempts   to   reduce   a   dislocation    have    been   described    in  Chapter 

xxxiy. 

The  injuries  which  are  more  or  less  frequently  associated  with  dis- 
locations of  the  shoulder,  but  which  are  without  such  special  bearing 
upon  the  prognosis  or  treatment  as  would  make  them  actual  complica- 
ti(ms,  have  been  mentioned  in  connection  with  the  different  forms  of 
dislocation  in  the  preceding  chapters.  The  most  im])ortant  are  the 
lacerations  of  the  different  muscles  and  tendons  or  their  equivalent 
avulsion  from  the  humerus  with  more  or  less  of  the  tuberosities  to 
which  they  are  attached. 

Laceration  of  the  subscapularis  is  frequent,  and  avulsion  of  the 
lesser  tuberosity  to  which  it  is  attached  is  very  rarely  substituted  for 
it,  apparently  only  in  some  of  the  backward  dislocations.  The  extent 
of  the  laceration  of  the  muscle  can  only  be  inferred  from  the  extent 
and  direction  of  the  displacement,  and  it  is  believed  to  be  without 
important  influence  upon  the  completeness  of  the  repair  and  the  subse- 
quent security  of  the  joint.  The  position  of  adduction  and  inward 
rotation  in  which  the  limb  is  habitually  kept  during  the  period  of  con- 
valescence favors  the  repair  of  the  muscle,  and  since  the  rupture  is 
usually  incomplete  the  torn  portions  do  not  widely  retract. 

With  the  muscles  attached  to  the  greater  tuberosity  it  is  somewhat 
different.  The  muscles  themselves  are  rarely  torn,  but  the  upper  and 
middle  facets  of  the  greater  tuberosity  to  which  the  supraspinatus  and 
infraspinatus  muscles  are  attached  are  frequently  broken  off  and  more 
or  less  retracted  under  the  acromion,  or  the  tendons  are  torn  away  from 
them  and  retracted.  The  importance  of  this  associated  injury,  through 
its  effect  upon  the  subsequent  usefulness  and  security  of  the  joint,  may 
be  great ;  not  only  may  the  power  of  voluntary  external  rotation  be 
diminished  thereby,  but  the  consequent  loss  of  supj)ort  on  tlie  outer 
side  of  the  joint  favors  recurrence  of  anterior  dislocation,  and  the  great 
lengthening  of  the  upper  portion  of  the  capsule  and  the  enlargement 
of  its  cavity  which  are  effected  by  the  retraction  of  the  su})raspinatns 
and  the  establishment  of  free  communication  between  the  joint  and  the 

(669) 


670  DISLOCATIONS. 

subacromial  bursa  make  the  joint  much  less  secure,  and  this  condition 
is  thought  to  be  a  cause  of  the  marked  tendency  to  recurrence 
observed  after  some  anterior  dislocations  (see  Chapter  XXIX.).  Sim- 
ilarly the  avulsion  or  rupture  of  the  subscapularis  in  backward  dislo- 
cations is  responsible  for  the  tendency  to  recurrence  that  has  been  so 
frequently  noted  in  them. 

The  tendon  of  the  long  head  of  the  biceps  appears  habitually  to  escape 
rupture  ;  its  sheath  may  be  opened  by  the  avulsion  of  either  tuberosity, 
and  then  it  may  slip  over  the  corresponding  portion  of  the  head,  and, 
becoming  engaged  between  the  latter  and  the  glenoid  cavity,  thus  con- 
stitute a  serious  obstacle  to  reduction.  When  ruptured,  its  end  is 
retracted  into  its  sheath  in  the  bicipital  groove  and  there  becomes 
united  with  the  bone. 

Fracture  of  the  greater  tuberosity  appears  to  be  not  often  capable 
of  demonstration  ;  at  least  it  has  often  been  found  post  mortem  when 
it  had  not  been  recognized  during  life,  although  the  proper  explanation 
of  the  failure  to  recognize  it  may  be  that  it  was  not  sought  for.  If 
the  fragment  is  retained  in  contact  with  the  humerus  by  the  untorn 
periosteum,  crepitus  may  perhaps  be  obtained  by  manipulation  ;  and 
when  the  fragment  is  widely  withdrawn  it  may  perhaps  be  felt  under 
the  acromion,  or  its  absence  may  be  recognized  by  the  change  in  the 
shape  of  the  corresponding  part  of  the  humerus,  or  the  fracture  may 
be  indicated  by  exceptional  symptoms  accompanying  the  dislocation, 
such  as  greater  mobility  of  the  limb  or  the  absence  of  fixed  abduction 
of  the  elbow,  or  local  pain  on  pressure.     (See  page  246.) 

Fracture  of  the  lesser  tuberosity  is  much  less  frequent.  (See  page 
248.) 

Fracture  of  the  Anatomical  or  Surgical  Neck.  This  serious  complica- 
tion of  the  humerus  is  fortunately  rare ;  McBurney  ^  was  able  to  collect 
only  117  reported  cases,  although  his  search  was  aided  by  those  of 
Oger  ^  and  Porrier  and  Mauclaire.^  Buchanan,^  reporting  a  personal 
case,  gives  a  large  and  interesting  collection  of  reported  specimens  and 
cases  of  fracture  of  the  anatomical  neck.  See  also  article  by  Mason  in 
the  same  number  of  the  Annals  of  Surgery,  in  which  he  gives  63  cases 
subsequent  to  McBurney's  collection. 

It  is  believed  that  the  fracture  follows  the  dislocation,  but  it  is  pos- 
sible that  they  may  be  coincident  in  fracture  of  the  surgical  neck  when 
the  dislocation  is  caused  by  violence  acting  on  the  outer  aspect  of  the 
shoulder.  Fracture  of  the  anatomical  neck  is  difficult  of  explana- 
tion. The  probable  cause,  in  my  opinion,  is  the  wedge-like  action  of 
the  inner  edge  of  the  glenoid  fossa  against  the  anatomical  neck  (see 
page  637) .  I  have  seen  it  in  one  case  of  dislocation  in  an  epileptic  con- 
vulsion, during  which,  it  was  said,  the  patient's  wrists  were  firmly 

'  McBurney  .  Annals  of  Surgery,  April,  1894,  and  May  1896, 

^  Oger :  Luxations  scapulo-humerales  compliquees  de  fracture.  These  de  Paris,  1884. 
No.  361. 

•^  Porrier  and  Mauclaire:  Rev.  de  Chir.,  October,  1892. 
*  Buchanan  :  Annals  of  Surg.  1908,  vol.  xlviii.,  659. 


DISLOCATIONS  OF  THE  SHOULDER.  671 

held  at  his  side  by  an  attendant.  Buchanan's  suggestion  that  this  acti(3n 
is  made  effective  by  forcible  lowering  of  the  abducted  elbow  after  disloca- 
tion seems  plausible,  but  I  have  been  unable  to  confirm  it  by  experiment. 

The  fracture  may  occupy  the  anatomical  or  the  surgical  neck,  or  may 
extend  through  the  tuberosiries,  or  may  be  extensively  comminuted. 
Of  68  cases  collected  by  Thamhayn  ^  the  fracture  in  14  was  of  the 
anatomical  neck  ;  in  2  of  these  reduction  was  eifected.  The  displace- 
ment in  the  great  majority  of  cases  is  forward  and  inward,  the  head 
lying  under  or  on  the  inner  side  of  the  coracoid  process  ;  in  a  few  cases 
it  has  been  backward  under  the  acromion.  The  upper  fragment  may, 
in  addition,  undergo  rotation  that  will  widely  separate  its  broken  sur- 
face from  that  of  the  shaft.  Cases  of  the  rare  form  in  Avhich  the  head, 
after  fracture  of  the  anatomical  neck,  has  undergone  complete  reversal 
while  remaining  within  the  cavity  of  the  joint  have  been  quoted  in 
Chapters  XIX,  and  XXIX,  The  upper  end  of  the  lower  fragment 
is  usually  drawn  upward  toward  the  glenoid  fossa,  overlapping  the 
upper  fragment  on  the  outer  side,  and  it  may  unite  in  this  position  by 
fibrous  or  bony  union  with  the  other  fragment,  or  with  the  scapula. 

The  upper  fragment  usually  preserves  its  vitality  and  establishes  new 
vascular  connections ;  in  rare  instances  it  has  become  necrotic  and  has 
been  eliminated  after  prolonged  suppuration. 

The  diagnosis  appears,  in  some  cases,  to  have  presented  serious 
difficulties,  because  the  fracture  removed  some  of  the  most  character- 
istic symptoms  of  the  dislocation,  such  as  the  fixation  and  attitude 
of  the  limb,  and  the  indication  of  the  position  of  the  head  of  the 
bone  that  is  furnished  by  the  direction  of  its  long  axis.  In  general 
terras,  it  may  be  said  that  when  the  dislocation  of  the  head  has  been 
recognized  the  coexistence  of  a  fracture  may  be  suggested  by  the 
mobility  of  the  limb,  its  shortening,  and  the  greater  extent  of  the 
ecchymosis,  and  proved  by  the  independent  mobility  of  the  shaft  and 
head  with  crepitus.  When  the  signs  of  fracture  are  apparent  the  coex- 
istence of  a  dislocation  can  only  be  recognized  by  determining  the 
absence  of  the  head  from  its  socket,  and  this  may  be  made  very  diffi- 
ouit  by  the  swelling  of  the  soft  parts.  It  must  be  remembered  that 
the  same  exceptional  mobility  may  be  given  to  the  limb  by  extensive 
laceration  of  the  capsule  WMthout  fracture.  The  two  positive  signs, 
which  the  surgeon  should  spare  no  pains  to  recognize,  are  the  absence 
of  the  head  of  the  humerus  from  its  socket,  which  proves  the  disloca- 
tion, and  its  failure  to  share  in  movements  communicated  to  the  shaft, 
which  proves  the  fracture. 

The  treatment  presents  grave  difficulties  because  the  existence  of 
the  fracture  deprives  the  surgeon  of  that  control  over  the  move- 
ments of  the  head  of  the  bone  which,  in  a  simple  dislocation,  can  be 
exerted  through  its  shaft.  Reduction  in  a  recent  case  may  some- 
times (36  out  of  80  cases,  Oger)  be  effected  by  direct  impulsion  of  the 
head  back  into  place.  This  should  always  be  attempted,  with  the  aid 
of  ansesthesia  and  gentle  traction  upon  the  abducted  shaft  in  order  to 
utilize  such  periosteal  connection  between  the  fragments  as  may  remain. 

iThamhayn:  Schmidt's  JahrVjiicher,  1861,  vol.  cxl.  p.  194. 


672  msLocATioxs. 

In  two  cases  of  fracture  of  the  anatomical  neck  I  made  reduction  m 
this  manner  very  easily,  holding  the  limb  in  full  abduction  and  press- 
ing directly  upon  the  head  with  the  fingers  deeply  placed  in  the  axilla. 
This  failing,  the  alternative  plans  were  to  seek  consolidation  of  the 
fracture  and  then  to  reduce  the  dislocation,  or  to  prevent  union  of  the 
fracture  and  thus  obtain  a  false  joint  at  its  seat  (Riberi),  or  to  excise 
tlie  fragment.  Xine  reported  cases  of  the  first  plan  gave  seven  failures 
and  two  successes,  and  even  in  one  of  the  latter  reduction  was  made  in 

Fig.  405. 


McBurney's  hook  for  making  tractioD  upon  the  dislocated  upper  fragment 


the  third  week.  In  5  cases  Dollinger  by  open  operation  reduced  2,  re- 
sected 2,  and  improved  the  altitude  of  the  limb  by  osteotomy  in  1. 
Seven  cases  of  the  second  plan  have  been  reported,  but  it  is  not  easy 
to  determine  from  the  reports  the  measure  of  the  functional  success. 
In  cases  in  which  the  displacement  was  unrelieved  the  usefulness  of  the 
arm  was  even  more  impaired  than  when  an  uncomplicated  dislocation 
was  left  unreduced,  because  of  the  additional  adhesions  created  by  the 
fracture,  and  a  large  proportion  of  the  patients  appear  to  have  suffered 
from  the  pressure  effects  of  the  dislocated  head.  The  complication, 
therefore,  remained  a  serious  reproach  to  surgery,  the  only  means  of 
relief  being  excision  of  the  head. 

In  this  juncture  Dr.  McBurney  devised  and  successfully  used  a 
method  of  reduction  which  seems  perfect  in  its  efficiency  and  which, 
at  least  when  the  fracture  is  through  the  surgical  neck,  involves  less 
risk  than  primary  excision  of  the  fragment.  He  makes  an  incision  on 
the  outer  anterior  aspect  down  to  the  upper  fragment,  drills  a  hole  in 
the  latter,  inserts  the  end  of  a  stout  hook  bent  at  a  right  angle  (Fig. 
405),  and  with  its  aid  makes  the  needed  traction  and  rotation.  After 
reduction  has  been  thus  made,  he  sutures  the  fragments  together  with 
catgut,  and  then  treats  the  liml)  as  for  fracture.  He  has  used  the  method 
in  four  cases,  two  each  of  the  surgical  and  anatomical  necks,  all  the 
wounds  healing  primarily,  and  witli  a  functional  result  as  good  as  that 
following  an  uncomplicated  dislocation  or  fracture. 

In  two  cases  in  which  I  employed  it  the  head  was  so  completely 
separated  from  all  attachments  that  it  seemed  best  to  remove  it,  and  in 
another,  five  weeks  after  the  accident,  I  made  no  attempt  to  preserve 
the  head,  believing  that  its  removal  would  give  a  better  functional 
result  in  view  of  the  advanced  age  of  the  patient,  his  epileptic  status, 
and  the  splintering  of  the  tuberosity. 


DISLOCATIONS  OF  THE  SHOVLbER.  673 

Sclilange^  has  recently  reduced  in  t\vo  case^ — one  a  fracture  of  che 
inatomical,  the  other  of  the  surgical  neck — by  incising  through  the 
axilla,  drawing  the  coraco-brachialis  forward  ana  the  vessel^^  and 
nerve.s  backward,  and  making  direct  reposition.  Mason  (above  quf)ted) 
reduced  through  an  anterior  incision,  after  fracture  of  the  surgical  neck, 
prying  the  head  into  position  with  an  elevator.  His  paper  contains 
full  late  statistics  and  a  discussion  of  the  methods  of  treatment. 

For  statistics  of  various  methods  of  treatment  after  failure  to  reduce, 
see  Souchon,  Transactions  of  the  American  Surgical  Association,  1897, 
p.  322  ;  B.  F.  Curtis,  Annals  of  Surgery,  March,  1900,  p.  291  ;  and 
Sehoch,  Beitrage  zur  klin.  C'hir.,  1901,  vol.  xxix.  p.  103. 

Fracture  of  the  shaft  associated  with  dislocation  of  the  shoulder  has 
also  l)een  observed  several  times.  It  is  a  less  serious  complication  than 
fracture  of  either  the  anatomical  or  the  surgical  neck,  because  the 
greater  length  of  the  upper  fragment  makes  it  easier  to  eifect  reduction. 

Fracture  of  the  coracoid  process  has  been  observed  in  connection 
with  dislocation  of  the  humerus,  not  only  in  the  case  of  supracoracoid 
dislocation  mentioned  al)ove,  but  also  in  dislocation  forward. 

Fracture  of  the  acromion  has  also  been  occasionally  observed. 
Kronlein's  and  my  cases  in  which  a  blow  received  upon  the  top  of  the 
shoulder  first  broke  the  acromion  and  then  dislocated  the  humerus  into 
the  axilla  have  already  been  mentioned  (p.  632) ;  also  Tuffier's,  in  an 
upward  dislocation. 

Fracture  of  the  Glenoid  Fossa.  Probably  the  chipping  of  the  edge 
of  the  glenoid  fossa  is  not  infrequent  in  dislocation,  and  ]:»asses  un- 
recognized because  of  the  lack  of  symptoms.  Fracture  of  a  large  por- 
tion has  been  occasionally  observed,  both  clinically  and  after  death, 
and  is  of  great  importance  in  favoring  recurrence  of  the  dislocation. 
Malgaigne  represents  in  his  Atlas  (Plate  XXIL,  fig.  4)  a  case  in  which 
the  anterior  third  of  the  fossa  was  broken  off  and  had  been  displaced 
backward  and  become  united  with  the  neck  of  the  scapula  ;  the  symp- 
toms in  the  case  were  that  the  shoulder  was  less  full  and  rounded 
than  normal,  and  that  the  head  of  the  humerus,  while  still  in  relation 
with  the  anterior  part  of  the  acromion,  projected  a  few  lines  in  front 
of  the  inner  border  of  the  coracoid  process. 

The  special  indication  for  treatment  is  to  prevent  recurrence  of  the 
dislocation  by  fixation  of  the  limb  and  pressure  upon  the  head  from 
the  side  on  which  the  fracture  has  taken  place. 

Nerves.  Injury  to  the  nerves,  except  of  a  slight  and  transitory 
character,  is  rare,  and  in  most  of  the  cases  reported  as  such  the  injury 
has  been  inflicted  during  reduction.  In  two  cases  in  which  the  injury 
was  demonstrated  by  post-mortem  examination,  Hilton's^  and  Parise's,^ 
there  was  only  a  partial  laceration  of  the  circumflex  nerve  in  the 
former,  and  in  the  latter  rupture  at  different  levels  of  the  fibres  com- 
posing it,  onlv  recognizable  on  minute  dissection  ;  the  nerve  trunk 
was  extensively  infiltrated  with  blood;  the  dislocation  was  subglenoid, 
and  the  nerve  was  tiy-htlv  stretched  around  the  head  of  the  humerus. 
In   Bourgues's*    (subglenoid)    the    main    nerves    were    so    con)pressed 

1  Schlange:  Arcli  fiir  kliii.  Cliir.,  vol.  Ixxxi.  Part  2,  p.  9. 
'  Hilton:  Guv's  Hospital  Reports,  1^47,  vol.  v.  p.  93. 
3  Parise:  Gaz.  ML-dicale  de  Paris,  1863,  p.  210. 
♦  Bourgues:  Bull,  de  la  Soc.  Anat.,  1888,  p.  581. 


674  DISLOCATIONS. 

between  tlie  surgical  neck  and  the  fascia  that  they  showed  multiple 
grooves  and  punctate  hemorrhages.  In  ]\Iuller's  (p.  497)  the  nerves 
and  artery  were  compressed  by  a  cicatricial  band. 

It  is  occasionally  found  in  unreduced  dislocations  that  the  sensibility 
of  the  skin  over  most  of  the  deltoid  region,  which  is  supplied  by  the 
circumflex  nerve,  is  diminished  or  lost,  and  that  in  others  after  reduc- 
tion the  deltoid  is  paralyzed.  This  paralysis  of  the  deltoid  is  thought 
frequently  to  be  the  result  of  direct  bruising  of  the  muscle  by  the 
violence  that  caused  the  dislocation,  but  that  explanation  does  not  sat- 
isfactorily account  also  for  the  loss  of  sensibility  in  the  skin,  and  we 
must,  in  such  cases,  assume  that  the  trunk  of  the  circumflex  has  been 
stretched  in  the  dislocation. 

In  many  of  the  reported  cases  it  cannot  be  determined  whether  the 
injury  to  the  nerve  was  caused  by  the  dislocation  or  by  the  manoeuvres 
made  to  effect  reduction;  in  some  it  is  clearly  due  to  the  dislocation. 
Illustrative  examples  have  been  quoted  in  Chapter  XXIX. 

The  cause  of  the  paralysis,  when  it  involves  more  than  the  circum- 
flex nerve,  is  very  obscure.  It  has  been  attributed  to  compression  of 
the  main  trunks  in  the  axilla,  but  this  explanation  is  not  satisfactorily 
supported  by  post-mortem  examination  or  experiment,  and  the  fact 
that  similar  symptoms  may  follow  blows  that  neither  produce  a  dislo- 
cation nor  directly  involve  the  nerves  adds  to  the  difficulty.  Xelaton 
sought  to  explain  it  by  supposing  a  compression  of  the  nerves  between 
the  clavicle  and  the  first  rib,  and  some  cases  have  been  reported  which 
indicate  that  this  explanation  may,  sometimes  at  least,  be  the  correct 
one.  Perhaps  elongation,  stretching  of  the  brachial  plexus  in  marked 
descent  of  the  head  may  be  a  cause.  Cf.  Flaubert's  case,  p.  528.  On 
the  other  hand,  the  prompt  disappearance  of  the  symptoms  in  some 
cases  after  reduction  clearly  points  to  pressure  by  the  head  or  neck 
of  t^jie  humerus  upon  the  nerves  as  the  cause. 

TThe  paralysis  may  appear  immediately  or  may  develop  gradually 
during  the  first  two  or  three  days,  and  it  may  be  complete  or  partial. 
In  some  cases  (see  Chapter  XXIX.)  it  has  been  followed  by  serious 
changes  in  the  appearance  and  nutrition  of  the  limb,  presumably  the 
effect  of  an  ascending  neuritis.  In  one  case  Bardenheuer^  demon- 
strated the  existence  of  neuritis  and  perineuritis  by  exposing  the 
nerves,  and  worked  a  gradual  cure  by  stretching  their  trunks. 

Whatever  doubt  may  exist  as  to  the  direct  cause  of  the  paralysis, 
the  first  step  in  the  treatment  is  to  reduce  the  dislocation  ;  after  that 
has  been  accomplished,  or  even  if  it  should  fail,  electricity  should  be 
persistently  employed.  Some  cases  respond  promptly  to  treatment,  the 
contractility  of  the  muscle  sometimes  reappearing  after  even  the  single 
application  of  a  blister,  while  others,  after  weeks  or  months  of  treat- 
ment, will  show  no  improvement.  So  long  as  the  muscle  reacts  to 
electrical  stimulation  the  prognosis  is  good. 

Bloodvessels.  The  complication  of  serious  injury  to  the  bloodves- 
sels   in    the    neighborhood  of  the  joint   is  not    frequent,   and  in  the 

'  Bardenheuer :  Loc.  cit.,  p.  335. 


DISLOCATIONS  OF   THE  SHOULDER.  675 

recorded  cases  there  is  often  a  doubt  whether  the  injury  was  caused  by 
the  dislocation  or  by  the  attempt  to  reduce  it.  The  subject  has  been 
discussed  in  detail  in  Chapters  XXIX.  and  XXXIV. 

Chest.  A  unique  case  reported  by  Prochaska,  in  which  the  head  of 
the  luunerus  was  forced  into  the  chest  between  the  second  and  third 
ribs,  is  quoted  in  Chapter  XXIX.,  p.  499. 

Compound  dislocations  are  rare  ;  the  wound  in  the  skin  is  commonly 
in  the  axilla,  sometimes  further  inward  through  the  pectoralis  major, 
sometimes  behind  the  joint.  It  is  a  very  serious  complication,  although 
there  is  reason  to  hope  that  a  larger  proportion  of  successes  will  be 
obtained  in  the  future  under  the  improved  methods  of  treating  wounds 
than  was  possible  in  the  past.  The  essentials  of  such  treatment  are 
immobilization  of  the  joint,  drainage,  and  surgical  cleanliness;  excis- 
ion of  the  head  of  the  humerus  may  also  be  required  under  certain 
circumstances,  such  as  difficulty  of  reduction  or  retention,  coincident 
fracture,  uncleanliness  of  the  wound,  and  imperfect  drainage  of  the 
joint.  The  prudent  course  is  to  provide  abundantly  for  drainage  by 
not  closing  the  skin  wound  except,  perhaps,  in  part,  and  by  lightly 
packing  with  iodoform  gauze  for  at  least  twenty-four  hours.  The  last- 
named  precaution  provides  a  prompt  and  ready  means  of  escape  for 
the  blood  and  exudations,  and  at  the  same  time  does  not  prevent  the 
wound  from  being  closed  a  day  or  two  later  with  sutures  and  then 
healing  as  rapidly  and  kindly  as  if  it  were  entirely  fresh. 

Simultaneous  dislocation  of  both  shoulders  is  deemed  a  rare  occur- 
rence ;  possibly  it  is  more  frequent  than  is  generally  supposed,  for  I 
found  five  cases  mentioned  in  the  Index  Medicus  for  the  years  1880  to 
1885.  It  is  of  interest  only  as  a  curiosity,  for  the  combination  does 
not  seriously  affect  the  prognosis  or  treatment.  The  causes  in  the  five 
cases  referred  to  were  as  follows  :  In  one  ^  the  patient  was  seized  in 
the  street  by  two  thieves  who  drew  his  arms  upward,  outward,  and 
backward,  producing  subcoracoid  dislocations ;  both  joints  had  pre- 
viously been  repeatedly  dislocated.  In  the  second  *  the  patient,  while 
standing  on  a  platform,  was  caught  under  one  arm  by  a  chain  and 
thrown  to  the  ground.  In  the  third*  a  woman,  eighty-six  years  old, 
fell  out  of  bed,  receiving  an  intracoracoid  and  a  subcoracoid  disloca- 
tion. In  the  fourth*  a  girl,  twenty-one  years  old,  was  knocked  down 
by  a  falling  wall ;  and  in  the  fifth,*  a  girl,  the  injuries  occurred  during 
an  epileptic  convulsion.  In  a  personal  case  both  shoulders  were  dislo- 
cated by  lifting  the  patient  by  his  hands  out  of  the  water  into  a  boat. 
All  of  them  were  anterior  dislocations.  Mention  has  been  made  in 
the  preceding  chapter  of  Bardenheuer's  case  in  AvLich  both  shoulders 
were  dislocated  backward  by  a  fall  forward  upon  the  elbows.  Anglada 
[Arch.  Interned,  de  Chir.,  1908  II.  6)  reports  a  case  and  collects  many 
pu])]ish('d  ones. 

Associated  dislocation  of  the  elbow  has  been  twice  reported.      Morel- 

1  G.  E.  Moore :  New  York  Medical  Record,  1880,  vol.  xviii.  p.  96. 

■iCaskie :  British  Medical  Journal,  1881,  ii.  p.  854. 

•^  Giiterbock :  Berlin,  klin.  Wochenschrift,  1885,  vol.  xii.  p.  346. 

■•Zinker:  Idem,  p.  418. 

*  Frankel :  Verhiandl.  Berlin,  med.  Gcsellschaft,  1885,  xiii.  p.  150. 


676  DISLOCAIIONS. 

Lavall^e's^  patient  was  injured  in  a  railway  accident ;  the  head  of  the 
humerus  was  driven  out  through  the  skin  of  the  outer  part  of  the 
shoulder  and  projected  so  far  that  the  elbow  was  in  contact  with  the 
axilla  ;  the  elbow  also  was  dislocated. 

Moxhay's^  patient  was  a  man,  fifty-six  years  old,  who  was  struck  on  the 
back  of  the  arm  by  the  handle  of  a  wrench  and  sustained  a  backward 
dislocation  of  both  bones  of  the  forearm  and  a  subcoracoid  dislocation  of 
the  shoulder;  the  latter  injury  was  not  discovered  by  the  surgeon  until 
the  seventh  week  after  the  accident ;   it  was  then  successfully  reduced. 

Injuries  caused  by  attempts  made  to  reduce  dislocations  have  been 
described  in  Chapter  XXXIV. 

PROGNOSIS  AND  AFTER-TREATMENT. 

Since  our  knowledge  of  the  pathology  of  dislocations  and  of  the 
common  obstacles  to  reduction  has  become  so  much  more  accurate 
and  complete,  and  especially  since  the  introduction  of  anaesthet- 
ics, failure  to  reduce  a  recent  dislocation  of  the  shoulder  has 
become  very  exceptional.  Bardenheuer  says  that  of  400  such  cases 
treated  by  him  within  ten  years  he  has  not  failed  in  any,  and 
only  once  has  he  had  any  difficulty.  I  have  been  obliged  to  resort 
to  the  knife  in  only  one.  The  prognosis,  therefore,  so  far  as  the 
reduction  of  recent  dislocations  is  concerned,  is  eminently  favorable. 
It  is  also  more  favorable  for  the  older  dislocations  than  it  formerly 
was,  for  the  same  reasons  and  because  of  the  greater  safety  of  opera- 
tive interference ;  and  at  the  same  time  such  cases  have  become  more 
uncommon,  for,  as  a  rule,  they  are  now  only  those  in  which  the  dislo- 
cation has  been  overlooked  or  not  treated. 

The  prognosis  is  also  favorable  as  regards  the  complete  restoration 
of  the  functions  and  security  of  the  joint,  but  this  restoration  may  be 
delayed  or  prevented  by  inflammation  or  partial  anchylosis  of  the 
joint  or  by  paralysis  of  some  of  the  muscles,  and  the  security  may  be 
seriously  diminished  by  partial  failure  of  repair  or  by  permanent 
changes  in  the  joint  surfaces. 

A  recent  investigation  by  Kiittner  ^  shows  surprisingly  unfavorable 
results.  Of  54  patients  whom  he  was  able  to  trace,  from  among 
those  treated  during  the  preceding  five  years,  only  7  (13  per  cent.)  had 
regained  full  use  of  the  limb  without  loss  of  strength  or  limitation  of 
motion;  in  14  (26  per  cent.),  the  range  of  motion  was  complete  but  the 
strength,  measured  with  a  dynamometer,  was  reduced  one-half  or  more. 
The  remaining  32  (61  per  cent.)  had  some  loss  of  motion,  which  in  26 
amounted  to  inability  to  raise  the  elbow  laterally  above  the  level  of  the 
shoulder.  All  the  cases  were  uncomplicated  and  had  been  treated  in 
hospital,  immobilization  for  a  week  followed  by  massage  and  mechano- 
therapy for  two  or  three  months.      Kiittner  thought  it  would  have 

1  Morel-Lavallee :  Bull,  de  la  Soc.  de  Chir.,  1858,  vol.  viii.  p.  490. 

2  Moxhay :  Lancet,  1882,  il.  p.  938. 

3 Kiittner;  Beilage  zum  Ztlblatt  fur  Chir.,  1908,  p.  155. 


DISLOCATIONS  OF  THE  SHOULDER.  677 

been  better  to  shorten  the  time  of  immobilization  ;  it  seems  to  me  that 
it  would  have  been  better  to  lengthen  it  and  to  have  used  passive 
motion  less  early  and  less  freely,  for  the  limitation  of  motion  was  doubt- 
less due  to  peri-articular  thickening  on  the  inner  side,  and  it  seems  not 
unlikely  that  the  torn  tissues  were  not  allowed  sufficient  time  to  regain 
their  softness  and  pliability. 

Goebel  ^  reports  similar  unfavorable  results  after  examination  of  24 
patients,  beneficiaries  under  the  German  social  legislation  :  12  had  full 
function,  but  all  complained  of  subjective  troubles  ;  the  other  12  showed 
some  limitation  of  motion.  The  fact  that  all  were  employes  receiving 
compensation  during  convalescence  needs  to  be  borne  in  mind.  Lexer  ^ 
found  in  40  oases  10  completely  restored,  15  with  some  limitation  of 
motion,  and  15  with  some  pain  and  loss  of  strength. 

The  after-treatment  is  directed  to  the  retention  of  the  head  of  the 
bone  in  its  place  until  such  time  as  the  repair  of  the  injuries  to  the 
capsule  and  peri-articular  tissues  is  sufficiently  advanced,  and  to  the 
prevention  or  cure  of  inflammation  and  anchylosis. 

It  occasionally,  though  very  rarely,  happens  that  the  dislocation  is 
reproduced  within  a  few  minutes  of  the  reduction,  without  such  move- 
ment of  the  arm  (abduction  or  elevation  of  the  elbow)  as  would  explain 
it,  and  it  is  then  presumably  due  to  muscular  contraction,  perhaps  aided 
by  the  interposition  of  a  portion  of  the  capsule.  It  suggests  the  de- 
sirability of  immediately  and  securely  fixing  the  arm  to  the  side  of  the 
body  before  the  patient  is  allowed  to  move  after  reduction  has  been 
made,  and  of  inspecting  the  limb  shortly  afterward. 

The  traumatism  is  always  followed  by  some  inflammatory  reaction 
and  the  evidences  of  a  more  or  less  prolonged  arthritis,  but  it  seldom 
happens  that  this  is  sufficiently  violent  to  cause  apprehension  or  require 
other  treatment  than  immobilization  of  the  limb.  The  severer  cases 
are  those  in  which  the  limb  has  been  too  early  or  too  freely  used. 
The  fear  that  prolonged  immobilization  of  a  joint  would  lead  to  its 
permanent  stiffness  is,  or  has  been,  too  prevalent  and  has  led  to  much 
untimely  passive  or  active  motion  of  joints  that  have  been  injured,  and 
this  in  turn,  by  keeping  up  the  irritation,  has  increased  the  stiffness 
which  it  was  designed  to  diminish.  After  the  soreness  has  ceased, 
about  the  third  week,  the  patient  should  be  encouraged  to  try  gently. 
to  increase  the  range  of  motion  and  freely  to  use  the  limb  within  the 
limits  of  pain.  The  retraction  of  the  capsule,  the  loss  of  its  pliability, 
is,  except  in  the  case  of  prolonged  inflammation  and  in  some  highly 
arthritic  individuals,  only  temporary  and  will  ordinarily  yield  to  the 
natural  use  of  the  limb. 

If  the  inflammation  is  more  severe  or  if  it  has  been  prolonged  by 
imprudent  use  of  the  limb  the  immobilization  should  be  supplemented 
by  traction  downward.  Bardenheuer^  highly  recommends  in  addition 
that  the  upper  end  of  the  humerus  should  be  kept  pressed  outward 
and  backward  by  a  pad  in  the  axilla  attached  to  a  weight  above  and 
behind  the  shoulder.     This  necessitates. the  recumbent  posture. 

1  Goebel :  Ztlblatt.  fiir  Chir.,  1909,  p.  1219. 
a  Lexer:   Reitriige  zur  klin.  Chir.,  vol.  Ixx. 
8  Bardenheuer:  Loc.  cit.,  p.  412. 


678  DISLOCATIONS. 

For  late  changes  in  the  bone  see  the  following  section  :  Habitual 
Dislocation. 

Paralysis  of  the  deltoid  causes  the  loss  of  voluntary  abduction  of 
the  arm,  and  if  prolonged  leads  to  permanent  shortening  of  the  lower 
and  inner  portion  of  the  capsule  with  consequent  limitation  of  even 
passive  abduction.  It  may  also  be  followed  by  the  sinking  of  the 
humerus  downward  through  lack  of  the  support  normally  given  by 
the  deltoid,  and  by  consequent  loss  of  security  in  the  joint.  Usually 
these  paralyses  get  well  spontaneously  or  under  treatment  by  blisters 
or  electricity,  but  sometimes  they  are  permanent. 

If  the  dislocation  remains  permanently  unreduced  the  peri-articular 
muscles  become  wasted  and  the  deformity  of  the  region  is  thereby 
increased.  The  head  forms  a  new  socket  for  itself,  but  its  availability 
for  motion  is  slight,  and  the  use  of  the  limb  is  confined,  as  a  rule,  to 
the  "  underhand  "  movements.  In  some  cases  the  compensatory  mo- 
bility of  the  scapula  is  such  that  the  hand  can  be  raised  to  the  head, 
and  in  some  a  degree  of  usefulness  has  been  exceptionally  obtained 
that  is  far  in  excess  of  what  is  usual.  Thus,  Prochaska's  patient, 
the  head  of  whose  humerus  was  lodged  in  the  chest  after  having 
passed  between  the  second  and  third  ribs,  earned  his  living  for  many 
years  as  a  woodc  hopper. 


HABITUAL    DISLOCATION. 

Habitual  dislocation,  by  which  is  meant  a  marked  tendency  to  the 
reproduction  of  the  dislocation  by  slight  causes,  such  as  the  abduction 
of  the  arm,  is  not  infrequent  and  may  constitute  a  serious  disability ; 
it  is  most  frequently  observed  after  anterior  dislocations,  but  appears 
to  be  relatively  more  common  after  the  posterior  ones. 

The  cause,  in  anterior  dislocation,  appears  not  to  be  a  constant  single 
one,  it  may  be  an  enlargement  of  the  upper  part  of  the  capsule  (JosseP), 
or  of  its  inferior  and  inner  portion  by  incomplete  repair  of  the  primary 
rent,  or  deformity  of  the  glenoid  fossa  or  head  of  the  humerus  either 
by  trauma  at  the  time  of  the  dislocation  or  by  the  slow  changes  of  a 
dry  arthritis. 

In  the  posterior  dislocations  the  cause  appears  to  be  loss  of  support 
by  detachment  or  rupture  of  the  subscapularis. 

Jossel's  findings  in  nine  autopsies  have  been  described  in  Chapter 
XXIX.,  p.  501,  an  enlargement  of  the  capsule  and  loss  of  support  by 
detachment  or  rupture  of  the  supra-  and  infraspinatus  muscles.  In 
only  one  of  his  cases  was  there  also  an  evidence  of  defective  repair  of 
a  rent  at  the  lower  inner  part  of  the  capsule. 

Laxity  of  the  lower  and  inner  portion  of  the  capsule  by  incomplete 
repair  of  the  rent  was  long  supposed  to  be  a  cause,  but  without  much 
anatomical  support  before  Turner  Thomas  ^  demonstrated  it  in  opera- 
tions through  the  axilla  for  relief  from  recurrence. 

Important  changes  in  the  head  of  the  humerus  and  the  glenoid  fossa 

i  Josscl :  Deutsche  Zeitschrift  fiir  Chir.,  1880,  vol.  xiii.  p.  167. 
2  Thomas:  Am.  Jouru.  Med.  Sc,  Feb.  and  March,  1909. 


HABITUAL   DISLOCATIONS  OF  THE  SHOULDER.  679 

have  been  shown  in  a  number  of  specimens.  Lobker  '  presented  at  tlie 
Fifteenth  Congress  of  German  Surgeons  a  specimen  obtained,  post-mor- 
tem, from  a  case  of  habitual  dislocation,  which  showed  changes  in  the  head 
and  glenoid  fossa  which  were  thought  to  be  the  effect  of  the  frequent  recur- 
rence, and  another  specimen  obtained  by  Vogt  by  excision  in  a  similar 
case  and  showing  the  same  changes  in  the  head  of  the  humerus.  The 
head  in  each  case  was  normal  only  on  its  inner  anterior  half;  the  other 
half  had  lost  its  roundness,  and  showed  a  depression  one  centimetre 
deep  and  two  centimetres  wide,  extending  from  top  to  bottom,  and 
separated  from  the  normal  inner  half  by  a  sharp  prominent  border. 
The  surface  was  covered  throughout  by  cartilage,  and  the  depression 
was  evidently  not  the  result  of  a  fracture  with  loss  of  substance.  The 
tuberosities  and  bicipital  groove  were  intact ;  the  long  tendon  of  the 
biceps  was  torn  from  its  insertion,  and  had  become  adherent  in  its 
groove.  There  were  evidences  of  the  avulsion  of  the  muscles  from 
the  greater  tuberosity.  The  outer  portion  of  the  glenoid  fossa  was 
normal,  and  separated  by  a  sharp  vertical  border  from  the  large  inner 
portion  which  was  angularly  deflected  backward.  Both  portions  were 
covered  with  cartilage,  and  showed  no  sign  of  fracture.  The  head 
and  fossa  fitted  together  in  such  a  way  that  the  inner  half  of  the  head 
articulated  with  the  inner  half  of  the  fossa,  and 
the  sharp    edge    of  the  latter  occupied    the  Fict-  ^06- 

depression  m  the  former. 

He  refers  to  the  fact  that  specimens  obtained 
by  excision  by  Cramer,  K Lister,  and  von  Volk- 
mauu  showed  similar  losses  of  substance  in 
the  head  of  the  humerus,  and  attributes  them 
to  the  frequent  recurrence  or  to  a  persistent 
subluxation  by  which  the  head  is  made  to  rest 
against  the  inner  border  of  the  fossa,  instead 
of  squarely  against  its  face. 

The  symptoms  presented  by  Lobker's  case      Horizontal  section  of  tine  head 
during  life  are  not  given,  but  it  does  not  seem   of  the  humerus  m  Cramer's  case 
possible  that  they  could  have  been,  at  least  ^  ^„'rrc:f T^fe'aierl^r 
at  the  last,  such  as  are  found  in  habitual  dis-    osity;  c,  lesser  tuberosity, 
location,  for  that  is  characterized  by  complete 

restoration  of  form  in  the  intervals  between  the  recurrences,  while  in 
this  case  the  subluxation  must  have  been  persistent. 

Three  cases  of  habitual  dislocation  in  which  the  head  of  the  humerus 
was  excised  are  referred  to  by  Lobker  as  showing  similar  losses  of  sub- 
stance in  the  humerus,  but  a  reference  to  the  original  reports  ^  shows 
that  in  all  three  the  loss  was  thought  to  be  the  result  of  a  fracture, 
although  in  the  discussion  on  one  of  them  (Kiister's),  Kiedinger  expressed 
the  opinion  that  it  was  due  to  absorption.  As  the  cases  ilhistratt'  also 
the  method  of  treatment  by  excision,  I  quote  two  of  them  bi'ietly. 

1  Lobker:  Beilage  zuni  Centralblatt  fiir  Chir.,  1886,  p.  90. 

2  Cramer:  Berlin,  klin.  Wochen.sclirift,  1882,  p.  21.  Volkniann,  rciiort.d  by  Popko: 
Znr  Kasnistik  und  Thcrapic  der  invetcrirtcn  und  habituellen  Scliiilterliixationi'n,  llnlle. 
1882.  Abstract  in  (Vntralblatt  fiir  Chir.,  188:5,  p.  28.  Kvister :  Beilage  zum  Centralblatt 
fiir  Chir.,  1882,  p.  73. 

47 


680  DISLOCATIONS. 

Cramer's  patient  was  a  woman  thirty  years  old,  who  dislocated  her 
shoulder  forward  and  inward  during  an  epileptic  fit,  and  again  in  another 
two  months  later ;  the  arm  was  then  immobilized  for  several  months,  and 
a  special  dressing  was  worn  most  of  the  time  afterward,  especially  at  the 
menstrual  periods,  when  the  attacks  of  epilepsy  were  most  likely  to  occur, 
but  nevertheless  the  dislocation  recurred  nineteen  times  within  five  years, 
each  time  during  a  fit ;  reduction  was  sometimes  easy,  sometimes  quite 
difficult,  and  the  patient  was  eager  to  be  relieved  of  the  annoyance  and 
the  dread.  The  head  was  excised  through  an  anterior  incision,  and  the 
patient  made  a  good  recovery.  The  functional  result  was  fairly  satis- 
factory and  was  still  improving  two  years  after  the  operation. 

The  articular  surface  of  the  head  of  the  humerus  showed  a  shallow  loss 
of  substance  on  its  outer  side  four  centimetres  long,  two  broad,  and  about 
three-fourths  of  a  centimetre  in  depth  at  the  centre  (Fig.  406),  and  there 
was  found  a  small  body  of  irregular  shape,  one  centimetre  in  its  greatest 
diameter,  with  a  smooth  surface,  and  attached  by  a  long,  thin  pedicle  to 
the  posterior  margin  of  the  glenoid  fossa.  It  was  composed  of  bone  cov- 
ered by  fibrous  tissue  with  bits  of  cartilage  between  them  in  places,  and 
was  thought  to  be  a  fragment  broken  from  the  head. 

In  Volkmann's  the  posterior  third  of  the  head  showed  a  smooth 
surface  not  covered  by  cartilage,  which  had  been  "  undoubtedly  "  pro- 
duced by  the  breaking  oif  of  a  wedge-shaped  piece.  No  such  fragment 
could  be  found  in  the  cavity,  and  it  was  thought  to  have  been  absorbed. 
The  glenoid  articular  fossa  was  altered  in  shape,  having  become  nar- 
rower below  than  above.  The  capsule  was  torn  away  from  the  inner 
and  lower  margin  of  the  glenoid  fossa,  thus  creating  an  opening  which 
communicated  with  the  subscapular  bursa.  On  the  thickened  edge  of 
this  opening  was  attached,  by  a  sort  of  pedicle,  a  piece  of  cartilage- 
covered  bone  "  which  was  evidently  the  remains  of  a  fragment  broken 
fr(jm  the  edge  of  the  glenoid  fossa."  (This,  if  so,  would  be  a  suffi- 
cient explanation  of  the  recurrence.)  The  patient  reported  that  the 
condition  of  his  arm  was  much  more  satisfactory  than  before  the 
operation. 

These  changes  in  the  bones  are  essentially  the  same  as  those  described 
in  cases  of  chronic,  non-suppurative  inflammation,  in  some  of  which  it 
is  evident  that  the  process  originated  in  a  dislocation.  (See  Gurlt, 
Path.  Anat.  der  Gelenkkrankheiten,  pp.  250-267,  and  especially  Curl- 
ing's case,  p.  280,  also  described  in  the  Medico-Ckirurgical  Transactions, 
1837,  vol.  XX.  p.  336,  as  a  partial  dislocation  forward.)  It  seems  not 
improbable  that  the  series  of  observed  changes  may  be  started  by  an 
ordinary  dislocation,  that  is,  by  one  that  is  not  distinguished  by  any 
exceptional  lesion  such  as  partial  fracture  of  the  head  or  of  the  edge 
of  the  glenoid  cavity  ;  this  is  followed  by  a  non-suppurative  arthritis 
which  so  modifies  the  capsule  and  the  shape  of  the  surfaces  that  a 
recurrence  of  the  dislocation  is  made  easy.  The  ])edunculated  bodies 
composed  of  bone  and  cartilage,  sometimes  found  in  the  joint  and 
thought  to  have  been  broken  from  the  head  of  the  humerus  or  the 
edge  of  the  glenoid  fossa,  may  be  of  new  formation.  In  three  of  four 
cases  reported  by  Burrell  and  Lovett,^  some  of  the  muscles  of  the 

1  Burrell  aud  Lovett :  Transactions  of  the  American  Surgical  Association,  1897,  p.  296. 


HABITUAL  DISLOCATIONS  OF  THE  SHOULDER.  681 

shoulder  were  notably  atrophied.  Additional  information  has  recently- 
been  supplied  by  Francke/  who  collected  18  cases,  Hildebrand/  who 
operated  upon  2,  and  Pertlies/  who  operated  upon  4  cases.  Francke 
thinks  enlargement  of  the  cavity  and  relaxation  of  the  capsule  the 
main  factor;  he  found  a  defect  in  the  head  of  the  humerus  in  12  of 
the  18  cases,  and  in  the  glenoid  in  9,  a  rent  in  the  capsule  at  the  edge 
of  the  glenoid  in  3,  and  rupture  of  the  outward  rotators  or  avul- 
sion of  the  greater  tuberosity  in  5,  and  free  or  pedunculated  bodies  in 
the  joint  in  5. 

Hildebrand  found  the  glenoid  defective  and  the  cavity  enlarged  by  a 
pouch  on  the  inner  side,  and  Perthes  found  rupture  of  the  outward 
rotators  in  2,  simple  enlargement  of  the  cavity  in  1,  and  wide  detachment 
of  the  capsule  and  periosteum  from  the  anterior  edge  of  the  glenoid  and 
adjoining  part  of  the  scapula  in  1. 

The  defect  in  the  head  is  habitually  situated  at  the  posterior  outer 
portion  in  the  form  of  a  deep  sharp  depression.  It  has  been  interpreted 
as  due  to  the  loss  of  a  fragment,  to  a  crush  against  the  edge  of  the 
glenoid,  and  to  absorption  after  bruising. 

Hildebrand  deepened  the  glenoid  fossa  so  as  to  give  it  a  raised  inner 
edge  and  packed  the  adjoining  pouch  with  gauze  in  order  to  cause  its 
wall  to  retract.  Perthes  reattached  the  outward  rotators  to  the  tuberosity 
in  2  cases,  made  a  tuck  in  the  capsule  (Ricard)  in  1,  and  by  an  ex- 
tensive operation  in  the  fourth  reattached  the  capsule  to  the  glenoid 
margin. 

The  frequency  of  recurrence  varies  greatly  in  the  different  cases;  in 
some  the  intervals  are  long,  in  others  the  dislocation  is  produced  every 
time  the  elbow  is  raised,  and  in  some  the  bone  can  be  voluntarily  thrown 
out  of  place  by  the  contraction  of  the  muscles. 

Ordinarily  reduction  is  very  easy,  and  the  patient  learns  to  effect  it 
himself;  in  others  it  is  at  times  difficult. 

The  treatment  by  injections  of  iodine  and  by  narrowing  the  capsule 
on  the  inner  side  has  been  mentioned  in  Chapter  XXXIII.,  p.  526 
The  latter  has  been  employed  successfully  by  its  introducer,  Ricard, 
in  two  cases,  by  myself  ^  in  three,  and  by  Willy  Meyer  {Annals  of  Surg., 
May,  1908,  p.  811)  in  one.  The  incision  occupies  the  interval  between 
the  deltoid  and  the  pectoralis  with  an  extension  from  its  upper  end 
outward  close  to  the  acromion  ;  the  corresponding  portion  of  the  del- 
toid is  detached  and  turned  outward.  In  the  anterior  portion  of  the 
capsule  thus  exposed  two  or  three  sutures  of  stout  silk  are  passed  so  as 
to  take  up  a  fold  about  three-quarters  of  an  inch  wide  and  running 
downward  and  outward,  or  a  long  narrow  piece  is  excised. 

In  one  of  my  cases  the  joint  was  extremely  loose,  the  head  slipping 
out  easily  either  in  front  or  behind  ;  the  original  injury  was  of  a  char- 
acter that  ensured  extensive  tearing  of  the  capsule.  After  the  narrow- 
ing of  the  capsule  in  front  the  head  no  longer  escai)ed  on  that  side  but 

^  Francke:  Deutsche  Zeitschrift  fiir  Chir.,  vol.  xlviii.  p.  309. 
2  Hildebrand  :  Arch,  fiir  klin.  C'hir.,  vol.  Ixvi.  ]).  ."'.(iO. 
^  Perthes:  Deutsche  Zeitsclirift  fiir  Chir.,  vol.  Ixxxv.  p.  199. 
*  Stimson  :  Anuals  of  Sur<,'cry,  March,  1898,  p.  364. 


682  DISLOCATIONS. 

still  slipped  backward  in  some  positions  of  the  limb;  the  patient  was, 
however,  so  satisfied  with  the  usefulness  of  the  limb  that  he  cared  for 
no  further  improvement. 

Burrell  ^  obtained  an  excellent  result  in  two  cases  by  excising  from 
the  anterior  inner  portion  of  the  capsule  a  piece  four  centimetres  long 
and  one  wide,  and  closing  the  gap  with  catgut  sutures.  For  better 
exposure  of  the  field  of  operation  he  divided  the  upper  three-quarters 
of  the  tendon  of  the  pectoralis  major  close  to  its  insertion,  and  part  of 
the  tendon  of  the  subscapularis. 

Grothe  ^  incised  the  anterior  portion  of  the  capsule  and  narrowed  it 
by  overlapping  the  sides  of  the  incision. 

Thomas  (quoted  above)  exposed  the  capsule  through  an  incision  in 
the  axilla,  passing  between  the  coraco-brachialis  and  the  vessels  and 
nerves  and  dividing  the  tendon  of  the  subscapularis ;  he  then  excised 
the  new  tissue  filling  the  gap  in  the  capsule  and  brought  the  sides  of 
the  rent  together.  The  result  was  excellent.  There  can  be  no  doubt, 
I  think,  that  in  an  unknown  proportion  of  cases  this  is  the  ideal  opera- 
tion, for  it  removes  the  predisposing  pathological  condition,  closes  the 
rent  in  the  capsule,  and  permits  as  satisfactory  an  examination  of  the 
interior  of  the  joint  for  abnormal  conditions  of  the  bones  as  the  anterior 
approach  does,  but  it  does  not  meet  the  indications  in  cases  of  the  first 
group,  those  in  which  the  outward  rotators  are  detached.  In  my  own 
cases  the  exposed  (antero-inner)  portions  of  the  capsule  showed  no 
signs  of  previous  injury  and  so  little  laxity  in  two  of  them  that  at  the 
time  I  hardly  dared  to  anticipate  any  benefit,  and  I  am  still  at  a  loss 
to  account  for  the  eminently  satisfactory  result.  But  the  result  was 
satisfactory,  as  it  was  also  in  the  other  cases  in  which  the  method  has 
been  employed,  and  that  clinical  fact  deserves  to  be  taken  into  account, 
especially  as  it  has  not  yet  been  learned  how  to  distinguish  between 
the  two  kinds  of  enlargement  of  the  capsule  previous  to  operation. 
That  Jossel  should  have  found  five  examples  of  his  lesion  in  an 
examination  of  all  the  bodies,  about  200,  brought  into  the  dissecting 
room  in  the  course  of  two  winters  indicates  a  notable  frequency  of 
the  condition,  and  also  that  it  may  probably  exist  without  causing  the 
disability. 

Dr.  J.  K.  Young^  reported  a  case  cured  by  an  operation  suggested 
by  Dr.  Allis,  namely,  division  of  the  lower  half  of  the  tendons  of  the 
pectoralis  major  and  latissimus  dorsi,  followed  by  maintenance  of  the 
limb  in  wide  abduction  during  repair  for  about  ten  days.  The  purpose 
of  the  operation  is  to  change  the  direction  of  the  pull  of  the  partly 
divided  muscles.  If  larger  experience  should  show  the  method  to  be 
trustworthy  its  simplicity  should  commend  it. 

Excision  of  the  head  of  the  humerus  has  been  resorted  to  in  at  least 
nine  cases,  and  the  reported  results  in  some  of  them  were  good.  I 
should  think  the  disability  would  have  to  be  great  to  justify  so  radical 
a  measure,  one  which  may  in  itself  by  so  disabling. 

1  Burrell  and  Lovett:  Transactions  of  the  American  Surgical  Association,  1897  p. 
296. 

2  Grothe:  Munch,  med.  Wochenschrift,  1900,  No.  19. 
'  Young:  Annals  of  Surg.,  March,  1916,  p.  375. 


OLD  DISLOCATIONS  OF  THE  SHOULDER.  683 

Yeates^  describes  an  apparatus  which  he  had  worn  with  com- 
fort and  advantage  to  Hmit  the  range  of  motion  and  thus  prevent 
recurrence. 

Another  class  of  cases  in  which  the  tendency  to  recurrence  is  the 
result  not  of  a  primary  traumatic  dislocation,  but  of  pathological  changes 
in  the  joint  or  of  paralysis  of  the  muscles,  will  be  considered  in  a  sub- 
sequent section. 

TREATMENT  OF  OLD  DISLOCATIONS.^ 

The  earlier  attempts  to  relieve  patients  of  the  pain  and  disability  of 
old  unreduced  dislocations  were  few  and  practically  limited  to  resection 
of  the  head  of  the  humerus  to  relieve  pain  and  give  some  mobility  and 
to  fracture  or  division  of  the  surgical  neck  of  the  humerus  to  improve 
the  attitude  of  the  limb  and  perhaps  give  some  mobility  by  preventing 
reunion.  For  their  historical  interest  may  be  mentioned  Despres's^ 
fracture  and  J.  Ewing  Mears's^  subcutaneous  division  of  the  surgical 
neck  with  a  view  to  obtaining  a  pseudarthrosis.  Mears  was  successful 
and  the  result  good;  in  both  of  Despres's  cases  the  fracture  reunited, 
but  the  patient  profited  by  the  change  in  the  attitude.  Pollaillon's^ 
subcutaneous  division  of  the  capsule  on  the  front  and  outer  side,  fol- 
lowed by  forcible  traction,  seems  to  have  rested  on  no  sound  basis  and 
to  have  deserved  the  neglect  which  has  overtaken  it. 

With  the  later  improvement  in  surgical  methods  and  a  wider  knowl- 
edge and  closer  study  of  the  pathological  conditions  came  an  increasing 
resort  to  attempted  reduction  by  arthrotomy  and  to  resection,  either 
primary  or  secondary  to  a  failure  to  reduce,  and  with  the  knowledge 
thus  gained,  and  especially  since  the  publication  of  Prof.  Dollinger's 
results,  it  may  fairly  be  claimed  that  the  principles  and  methods  of 
treatment  of  anterior  dislocations  are  reasonably  established. 

Many  of  the  arthrotomies  of  the  last  thirty  years  have  been  begun 
without  a  very  definite  idea  of  the  difficulties  to  be  overcome ;  the 
approach  has  usually  been  from  in  front,  between  the  deltoid  and  pec- 
toralis  major,  and  in  the  eff(:)rt  to  mobilize  the  humerus  and  free  the 
glenoid  fossa  the  dissection  has  been  so  detailed  that  either  a  later  re- 
section of  the  head  of  the  humerus  has  been  made  necessary  by  pro- 
longed suppuration  or  its  necrosis  or,  in  the  successful  cases,  the  peri- 
articular cicatrices  have  greatly  restricted  the  mobility  of  the  joint. 
Consequently,  notwithstanding  the  recognized  objections  to  its  results, 
primary  resection  instead  of  reduction  was  rather  generally  deemed  the 
operation  of  choice,  certainly  in  cases  with  marked  displacement  and 

1  Yeates:  Lancet,  June  30,  1888. 

2  For  bibliography  see  Knapp,  Beitriige  zur  klin.  Chir.,  1888,  vol.  iv;  Sohoch,  Ibid., 
1901,  vol.  xxix;  Engel,  Arch,  fiir  kUn.  Chir.,  1897,  vol.  Iv,  p.  60.3;  Smital,  Wiener  med. 
Wochen,  1890,  No.  .52;  Gwyer,  New  York  Medical  .Journal,  March  28,  1891 ;  Dolbet,  Arch, 
gen.  de  Med.,  1S93;  Souchon,  Transactions  of  the  .Vmerican  Surgical  -Association,  1897; 
Legueu,  I'lndependance  med.,  1901,  No.  15;  Schoch,  Bcitragc  zur  klin.  Chir.,  1901,  vtA. 
xxix,  p.  10.3;  Dollinger,  Deutsche  Ztschft.  fiir  Chir.,  1902,  vol.  Ixvi,  p.  .319;  SiK-iiccr,  I'roc. 
Royal  Soc.  of  Med.,  July,  1908;  Madelung,  Verhand.  Deutsche  Gcsel.  fiir  Chir.,  1909, 
vol.  xxxviii,  p.  276;  .Jonas,  Trans.  Am.  Surg.  Ass.,  1910,  vol.  xxviii,  p,  584. 

'  Despr^s:  Bull  de  la  Soc.  de  Chir.,  1S79,  vol.  xxii,  pp.  22  and  742. 
*  Mears:  Phil.  Med.  and  Surg.  Reporter,   1877,  vol.  xxxvii,  p.  287. 
6  Pollaillon:  Bull,  de  la  Soc.  de  Chir.,  1882,  p.  129. 


684  DISLOCATIONS. 

of  long  duration  and  in  those  complicated  by  fracture  of  the  surgical 
neck. 

Professor  Dollinger/  who  had  reached  the  conclusion  that  the  tension 
of  the  retracted  subscapularis  was  the  main  obstacle  to  reduction  in 
most  cases,  proposed  in  1902  to  meet  it  by  division  of  the  tendon  of 
that  muscle,  and  in  1911  he  published  his  integral  results,  39  operative 
cases,  an  experience  not  only  larger  than  that  published  by  any  other 
surgeon,  but  also  so  large  and  well  studied  as  to  give  great  weight  to 
his  conclusions.  His  entire  list  includes  43  cases  :  6  were  reduced  by 
mani})ulation,  33  by  arthrotomy  with  division  of  the  tendon  of  the  sub- 
scapularis, 2  by  arthrotomy  without  division  of  the  tendon,  in  3  primary 
resection  of  the  head  of  the  humerus  was  done  (2  of  them  complicated 
by  fracture  of  the  surgical  neck),  and  in  1,  also  with  that  fracture,  an 
osteotomy  was  done  to  improve  the  attitude  of  the  limb.  Of  the  33 
cases  in  which  the  tendon  of  the  subscapularis  w^as  divided,  8  suppu- 
rated, 4  in  the  first  6,  and  4  in  the  next  16  ;  in  2  of  these  subsequent 
resection  was  done,  and  in  1  death  was  caused  by  hemorrhage  from  the 
eroded  axillary  artery.  The  best  results  were  in  the  uncomplicated 
cases  in  which  the  dislocation  had  existed  about  two  months ;  they 
showed  from  two-thirds  to  three-fourths  of  the  normal  range  of 
motion. 

In  his  summary  of  the  methods  and  indications  for  treatment  he 
restricts  abstention  to  old  and  feeble  patients  and  to  dislocations  which 
have  existed  a  very  long  time  and  are  well  borne.  He  tries  to  reduce 
by  manipulation  only  when  the  head  is  quite  movable  and  the  greater 
tuberosity  is  not  shown  by  the  ir-rays  to  be  broken  off  and  lodged  in 
the  glenoid  fossa,  and  he  uses  but  little  force,  abandoning  the  effort  and 
resorting  to  arthrotomy  if  success  is  not  promptly  obtained.  Osteotomy 
he  employs  only  when  the  surgical  neck  has  been  broken  and  the 
callus  lias  established  such  connections  with  the  large  vessels  as  to 
make  its  liberation  dangerous.  Primary  resection  he  deems  definitely 
done  away  with  except  when  changes  in  the  head  of  the  humerus  or 
the  glenoid  fossa  contraindicate  reduction.  Reduction  by  arthrotomy 
and  division  of  the  tendon  of  the  subscapularis  he  deems  the  operation 
of  choice.  He  sometimes  precedes  it  with  a  gentle  effort  to  reduce  by 
manipulation ;  that  failing,  he  operates  after  waiting  eight  or  ten 
days. 

The  operation  is  done  through  an  incision  from  the  coracoid  down- 
ward along  the  inner  border  of  the  deltoid ;  the  deltoid  and  pectoralis 
are  separated,  the  coraco-brachialis  and  short  head  of  the  biceps  drawn 
inward,  the  pectoralis  minor  upward  ;  an  assistant  flexes  the  elbow  and 
rotates  the  arm  outward,  bringing  the  tendon  of  the  subscapularis  into 
sight ;  the  surgeon  divides  this,  and  reduction  is  then  made,  if  the  case 
is  uncomplicated,  by  rotation  of  the  arm.  The  tendon  is  then  sutured 
and  the  wound  closed. 

After  the  division  of  the  tendon  the  finger  can  be  readily  passed 
around  the  inner  side  of  the  head  to  explore  it  and  the  glenoid  fossa. 

•  Dollinger:  Zeitschrift  fur  Chir.,  1902-3,  vol.  Ixvi,  p.  319,  and  Ergebnisse  der  Chir. 
und  Orthop.,  1911,  vol.  iii,  and  Ztlblatt.  fijr  Chir.,  1911,  Beilage,  p.  117. 


BIRTH  DISLOCATIONS  OP  THE  SHOULDER.  685 

If  the  greater  tuberosity  is  thus  found  to  be  fixed  in  the  glenoid  fossa 
and  thus  to  be  a  bar  to  reduction,  he  covers  the  wound  carefully,  turns 
the  patient  upon  his  sound  side,  makes  a  second  incision  along  the  pos- 
terior border  of  the  deltoid,  and  through  it  reaches  and  frees  the  tuber- 
osity and  reattaches  it  to  the  humerus  by  a  suture  or  pin. 

He  thinks  it  essential  to  a  good  result  that  the  work  should  be  done 
with  as  little  dissection  and  handling  as  possible;  and  his  results  in  respect 
to  suppuration — 4  times  in  the  first  6,  4  in  the  next  16,  and  primary 
healing  in  the  last  11 — show  the  advantage  gained  by  experience. 

The  posterior  approach  by  incision  along  or  near  the  posterior  border 
of  the  deltoid  has  been  employed  in  one  case  each  by  Spencer  and 
Madelung  (see  Bibliography,  page  683),  with  division  of  the  spine  of 
the  scapula  and  reflection  of  the  acromion  by  the  latter,  and  is  warmly 
recommended  for  general  use.  It  may  prove  to  be  the  operation  of 
choice  when  the  greater  tuberosity  is  detached  and  lodged  in  the  glenoid 
fossa,  but  in  other  cases  the  anterior  route  seems  to  be  simpler,  to  re- 
quire less  dissection,  and  consequently  to  hold  out  the  hope  of  better 
functional  results. 

BIRTH  DISLOCATIONS. 

The  term  congenital  dislocation  as  commonly  heretofore  employed 
embraced  not  merely  dislocations  recognized  at  birth  but  also  another 
and  far  larger  class  in  which  the  time  of  the  appearance  of  the  deformity 
was  not  positively  known  but  was  thought  for  one  reason  or  another 
to  have  been  at  or  before  birth  or  in  early  infancy  and  in  which  there 
was  no  known  traumatic  cause.  They  presented  three  distinct  forms: 
(1)  one  due  apparently  to  irregular  development  of  the  joint;  (2)  one 
in  which  the  bones  are  normal  and  in  which  the  displacement  occurred 
during  intra-uterine  life  or  possibly  during  delivery;  (3)  a  third,  also 
with  normal  bones,  in  which  the  displacement  is  the  late  result  of  a 
paralysis  antedating  birth  or  caused  during  delivery. 

There  are,  in  addition,  cases  of  traumatic  dislocation  during  delivery 
in  which  the  nature  of  the  traumatism  and  the  nature  of  the  causative 
force  are  evident  and  the  condition  is  immediately  recognized  and 
corrected. 

As  observations  have  multiplied  and  investigation  has  progressed  it 
has  become  evident  that  the  vast  majority  of  these  so-called  congenital 
cases  belong  in  the  second  and  third  groups  and  probably  almost 
wholly  in  the  third  alone,  and  present  a  condition  which  is  of  much 
importance  because  of  the  frequency  of  its  occurrence,  the  disability 
which  it  creates,  and  its  amenability  to  treatment.  For  these  reasons 
and  because  there  is  nothing  congenital  about  the  condition  excei)t 
the  production  of  its  cause  at  the  time  of  birth,  it  is  best  treated 
separately  and  under  its  own  title,  yosterior  subluxations  of  infancy, 
a  sequella  of  birth  palsy. 

Another  group,  closely  allied,  is  made  up  of  birth  palsy  cases  in  which 
the  displacement  is  dift'erent  and  the  paralysis  more  extensiNc  or  more 


686  DISLOCATIONS. 

persistent,  and  of  others  in  which  the  causative  paraylsis  has  appeared 
subsequently  to  birth.  These  two  groups  will  be  considered  under 
Dislocations  Due  to  Paralysis. 

CONGENITAL  DISLOCATIONS. 

The  removal  of  the  two  groups  mentioned  above  leaves  only  a  few, 
and  in  the  main  doubtful,  cases  to  be  considered  under  this  title.  The 
subject  has  received  but  scant  attention  from  systematic  writers,  and 
the  reported  cases  (excluding  of  course  the  numerous  paralytic  cases 
habitually  described  under  this  title)  are  very  few.  Guerin^  formulated 
three  varieties  on  the  basis  of  three  observed  cases.  Two  of  them,  on 
the  facts  given,  have  no  title  to  consideration.  The  first  was  a  flail- 
joint,  bilateral,  in  a  lad  ten  years  old;  the  causative  paralysis  may, 
of  course,  have  antedated  birth.  The  second  was  an  old  bilateral 
anterior  dislocation  with  persistent  wide  abduction,  and  no  other  facts 
given.  He  adds  that  Roux  also  saw  this  case;  but  Malgaigne,  in  his 
rather  contemptuous  and  hostile  review  of  Guerin's  statements,  says 
that  Roux  told  him  he  had  never  seen  a  case  of  congenital  dislocation 
of  the  shoulder.  Guerin's  third  form  is  "Subluxation  upward  and 
outward,  characterized  by  a  sliding  of  the  head  of  the  humerus  in 
that  direction.  This  sliding  is  favored  by  the  pushing  back  of  the 
coracoid  and  acromion.  I  saw  this  variety  in  a  youth  fifteen  years 
old."  He  also  showed  to  the  Academy  at  the  same  time  a  foetus 
symele^  presenting  a  similar  dislocation  on  both  sides.  Unfortunately 
no  other  facts  are  given  about  either  case.  The  latter  might  have 
proved   to   be   a   unique   specimen. 

R.  W.  Smith^  in  a  paper  which  antedates  Guerin's  and  the  substance 
of  which  was  reprinted  in  his  book  in  1847,  says  he  could  find  no  mention 
of  the  subject  in  literature.  He  describes  three  cases  of  subcoracoid 
dislocation,  one  of  them  bilateral,  and  one  case  of  bilateral  subacromial 
dislocation.  In  his  paper  he  gives  at  length  his  reasons  for  believing 
the  subcoracoid  cases  to  be  congenital  and  not  old  traumatic  cases, 
so  this  ascription  of  a  congenital  origin  was  deliberate  and  reasoned 
and  is  therefore  not  to  be  lightly  rejected.  But  a  review  of  his  argu- 
ment, and  particularly  of  the  fact  that  he  offers  in  support  of  it  a  case 
of  Curling's  as  almost  identical  in  its  anatomical  findings,  but  which 
I  think  is  clearly  a  case  of  recurrent  dislocation,  confirms  my  earlier 
opinion  that  his  cases  also  were  old  paralytic  or  unreduced  traumatic 
dislocations.  Figs.  392  and  393  show  the  new  socket  and  head  of 
the  humerus  on  one  side  of  his  bilateral  subcoracoid  case.'* 

'  Guerin:  Recherches  sur  les  luxations  congenitales,  1841,  p.  30. 

2  One  in  which  the  lower  limbs  are  united  throughout  almost  their  entire  length  and 
terminate  in  two  feet. 

^  Smith :  An  essay  on  the  original  or  congenital  luxations  of  the  upper  extremity  of  the 
humerus,  Dublin  Journal,  1839,  vol.  14,  p.  249,  and  Treatise  on  Fractures,  1847. 

■•  In  Smith's  case  of  double  subcoracoid  dislocation,  a  lunatic  woman  twenty-nine  years 
old,  "there  existed  on  the  left  side  scarcely  any  trace  of  an  articulating  surface  in  the 
situation  which  the  glenoid  cavitj^  occupies  in  the  normal  state;  but  there  had  been  formed 
upon  the    costal  surface  of  the  scapula  a  socket  of  a  glenoid  shape,  measuring  about  an 


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CONGENITAL  DISLOCATIONS  OP   THE  SHOULDER. 


687 


In  his  habitual  subacromial  case,  a  lunatic  woman,  forty-two  years 
old,  "there  was  no  case  (trace  ?)  of  a  glenoid  cavity  on  the  natural 
situation,  but  upon  the  external  surface  of  the  neck  of  the  scapula 
there  was  a  well  formed  socket  which  received  the  head  of  the  humerus. 
It  was  directed  outward  and  forward,  was  covered  with  cartilage,  and 
surrounded  by  a  perfect  glenoid  ligament.  The  tendon  of  the  biceps 
muscle  arose  from  the  most  internal  part  of  its  superior  extremity, 
whence  it  passed  downward  and  outward  very  obliquely  in  order  to 


Fig.  407. 


Fig.  408. 


R.  W.  Smith's  case  of  double  congenital  subcoracoid 
dislocation  of  the  shoulder.     Scapula  of  left  side. 


The  same:  left  humerus. 


reach  the  bicipital  groove  of  the  humerus.  .  .  .  The  greater 
tubercle  was  natural,  but  the  lesser  was  elongated  and  curved,  forming 
a  most  remarkable  process;  it  was  an  inch  in  length  and  bore  some 
resemblance  to  the  coracoid  process  of  the  scapula.  At  its  root  it 
presented  a  smooth,  convex,  pulley-shaped  surface,  round  which 
passed  the  tendon  of  the  biceps  muscle."  The  case  was  first  seen  by 
Smith  on  the  autopsy  table  in  the  asylum  of  which  the  patient  had 
long  been  an  inmate. 


inch  and  a  half  in  its  vertical  direction  and  an  inch  and  a  quarter  transversely  (Fig.  407). 
It  reached  upward  to  the  under  surface  of  the  coracoid  process,  from  which  the  head  of 
the  humerus  was  merely  separated  by  the  cap.sular  ligament."  The  glenoid  ligament, 
perfect  in  every  respect,  extended  all  around  it.    The  capsule  was  perfect. 

The  head  of  the  humerus  (Fig.  408)  "was  of  an  oval  shape,  its  long  axis  corresponding 
with  the  shaft  of  the  bone.  The  oval  shape  was  principally  due  to  the  doficieiicy  of  its 
posterior  part,  and  there  existed  between  the  greater  tubercle  and  the  margin  of  the 
head  of  the  bone,  where  the  inverting  cartilage  terminated,  a  l)roafl,  shallow  depression 
corresponding  to  the  edge  which  separatcfl  (he  normal  from  the  aljiiormal  portion  of  the 
glenoid  cavity.    The  shaft  of  the  humerus  was  small  and  seemingly  atrophied." 


688  DISLOCATIONS. 

To  my  mind  the  description  of  the  origin  and  course  of  the  long 
tendon  of  the  biceps  and  of  the  lesser  tuberosity  of  the  humerus  is 
strong  proof  of  an  original  normal  development  with  late  modifications 
due  to  early  and  possibly  pre-natal  persistent  dislocation,  and  it  does 
not  seem  justifiable  to  attribute  it  to  a  maldevelopment  of  the  skeleton. 

Fifteen  years  later  Mayer,'  in  an  elaborate  paper  on  congenital 
dislocations  of  various  joints,  reported  three  personal  cases  of  the 
shoulder  and  quoted  three  other  reported  ones,  d'Outrepont,  Melicher, 
Ammon.     His  first  was  a  gravely  misdeveloped  child  that  lived  only 

Fig.  409. 


Congenital  subspinous  dislocation  of  the  shoulder. 

two  hours.  During  his  two  hours  of  life  the  left  upper  limb  showed 
only  slight  movements  of  the  fingers ;  the  other  three  limbs  were  moved 
actively.  There  was  a  subcoracoid  dislocation  of  the  left  shoulder; 
an  autopsy  was  refused ;  on  palpation  the  head  of  the  humerus  appeared 
normal,  the  glenoid  fossa  partly  absorbed,  and  a  new  one  partly  formed. 
Of  the  second  case,  a  man,  thirty-six  years  old,  the  only  description 
is  that  the  dislocation  was  subcoracoid  of  the  left  shoulder,  and  "that 
the  appearance  of  the  limb,  its  uselessness,  and  the  atrophy  of  the 
shoulder  and  upper  arm  are  quite  like  Smith's  cases." 


1  Mayer:  Verhand.  der  Physik-Med.  Gesellschaft  in  Wlirzburg,  1855,  vol.  v,  p.  247. 


CONGENITAL  DISLOCATIONS  OF   THE  SHOULDER.  689 

The  third  was  a  boy  with  a  flail-joint  and  almost  complete  paralysis 
of  the  shoulder,  arm,  and  forearm. 

He  repeats  a  personal  statement  made  to  him  by  d'Outrepont  in 
connection  with  his  own  first  case.  d'Outrepont  was  consulted  by  a 
pregnant  woman  for  relief  from  the  violent  movements  of  the  child 
she  was  carrying;  they  were  often  so  strong  that  they  could  be  seen 
through  the  mother's  clothes  and  had  a  "regular  G-hour  typus;"  after 
long  and  fruitless  treatment  the  child  died  during  an  attack.  The 
delivery  was  easy  and  unaided  and  there  was  a  double  subcoracoid 
dislocation.  Of  Melicher's  case  there  are  no  details  except  that  it 
was  subcoracoid  and  irreducible.  Ammon's  case  was  subcoracoid, 
the  limb  was  useful,  but  the  range  of  motion  at  the  shoulder  was 
restricted. 

The  papers  that  have  appeared  since  those  above  quoted  and  the 
many  cases  reported  under  the  title  "congenital"  have  dealt  mainly 
with  the  backward  dislocations  associated  with  partial  paralysis  which 
are  considered  below. 

Much  that  is  necessary  to  a  positive  opinion  of  the  origin  of  the 
displacement  in  these  fourteen  cases  is  lacking.  We  are  thrown  back 
upon  conjecture.  But  it  can  be  properly  claimed  that  in  only  three  of 
them — Guerin's  foetus,  Mayer's  first  case,  and  d'Outrepont — can 
it  be  safely  said  that  the  displacement  antedated  birth,  and  in  only 
one  of  these  (Guerin's)  can  it  be  plausibly  attributed  to  defective 
development  of  the  skeleton,  and  that  not  because  of  any  data  con- 
cerning the  shape  of  the  bones,  but  simply  because  of  the  existence  of 
other  faults  of  development  and  the  absence  of  any  more  plausible 
explanation.  Mayer's  case  showed  even  greater  faults  of  development — 
a  large  abdominal  median  gap  and  ectopy  of  the  heart — but  the  limb 
was  paralyzed  and  although  the  dislocation  is  described  as  subcoracoid 
the  account  shows  that  it  was  probably  a  flail-joint.  d'Ontrepont's 
was  probably  traumatic  (violent  movements  during  intra-uterine 
life)  either  by  muscular  action  or  by  the  pressure  of  the  uterine  wall 
while  the  limb  was  in  a  favorable  position. 

There  are  then  three  classes  of  dislocation  antedating  birth: 

1.  One  due  to  defective  development  (doubtful). 

2.  One,  traumatic,  during  intra-uterine  life. 

3.  One  due  to  paralysis  antedating  birth. 

Of  the  first  we  know  nothing.  Remedial  measures,  if  any,  would 
probably  be  limited  to  attempts  to  mitigate  the  disability  by  changing 
the  attitude  of  the  limb.  The  second  is  essentially  the  same  as  old 
unreduced  dislocations  received  after  birth;  and  in  the  third,  so  far 
as  it  is  independent  of  the  paralysis,  we  can  seek  only  for  some  means 
of  improving  function. 


690  DISLOCATIONS. 


POSTERIOR  SUBLUXATIONS  OF  INFANCY.^ 

More  or  less  extensive  paralysis  of  the  arm  existing  at  birth  is  of 
rather  frequent  occurrence.  Fairbank  reports  35  cases  seen  in  the 
"last  three  years  or  so,"  and  A.  S.  Taylor  in  a  personal  communication 
tells  me  he  has  operated  upon  48  cases,  and  has  seen  about  100  others. 
Of  37  of  Fairbank's  cases  in  which  dislocation  was  noted,  28  showed 
posterior  dislocation  in  varying  degrees,  less  in  the  earlier,  more  marked 
in  the  older  cases.  In  Dr.  Taylor's,  fully  50  per  cent,  of  the  operated 
cases  showed  the  displacement,  and  a  still  larger  percentage  of  the 
others  which  were  generally  cases  of  longer  standing  than  those  operated 
on.  In  2  of  his  operated  cases  the  paralysis  involved  more  muscles  than 
usual  and  the  condition  was  that  of  flail-joint.  The  paralyzed  muscles 
are  the  spinati,  deltoid,  biceps,  coraco-brachialis,  and  supinators, 
innervated  mainly  by  nerves  coming  through  the  fifth  and  sixth  cervical 
trunks.  Part  of  the  pectoralis  major  is  sometimes  involved,  and  there 
are  anatomical  reasons  for  thinking  that  the  same  is  true  of  the  sub- 
scapularis,  although  clinically  its  continued  activity  is  evident. 

Elongation  and  depression  of  the  anterior  portion  of  the  acromion 
(and  more  rarely  of  the  end  of  the  coracoid)  has  been  noted  by  several 
and  even  found  to  be  so  marked  as  to  constitute  a  definite  obstacle 
to  reduction.  Thomas  found  it  in  most  of  his  cases  and  thinks  it  is  the 
contemporaneous  effect  of  an  original  violence  which  caused  the 
dislocation.  I  believe  it  to  be  of  later  slow  production,  a  manifestation 
of  a  tendency,  often  noted  at  other  points,  toward  overgrowth  of  a 
bone  when  it  has  been  relieved  of  a  normal  pressure. 

The  cause  of  the  paralysis  seems  to  have  been  definitely  found  in 
an  injury  to  the  nerves  caused  by  forcible  separation  of  the  shoulder 
and  neck.  The  injury  has  been  demonstrated  in  many  cases  by  opera- 
tion or  autopsy,  and  consists  of  a  more  or  less  extensive  laceration  or 
rupture  of  one  or  more  bundles  of  the  cervical  plexus,  usually  well 
outside  of  the  vertebrae  but  sometimes  at  the  very  root  of  the  nerve. 
In  a  few  cases  (Lange,  Thomas)  the  nerves  have  been  found  injured 
at  a  lower  level,  in  the  immediate  neighborhood  of  the  shoulder-joint, 
and  Thomas  argues  from  this  and  other  facts  that  the  paralysis  is  the 
result,  not  the  cause,  of  the  dislocation.  The  separation  of  the  shoulder 
and  neck  may  be  occasioned  in  vertex  presentation  by  traction  upon 
the  head,  and  in  breech  presentation  by  traction  upon  the  trunk  and 
shoulder  made  to  free  the  head.  Difficult  delivery  has  been  noted  in 
a  large  proportion  of  cases. 

'  Bibliography.  In  addition  to  perhaps  a  score  of  individual  cases  in  periodical  litera- 
ture noted  in  the  Index  Catalogue  of  the  Surgeon-General's  Library  see  previous 
editions  of  this  work  and  Marston:  N.  Y.  Med.  Journal,  1901,  vol.  73,  pp.  441,  529; 
C'umston:  Am.  Journ.  Med.  Sc,  1903,  vol.  125,  p.  967;  Clark,  Taylor  and  Prout:  idem,  Oct., 
1905;  Whitman:  Annals  of  Surg.,  1905,  vol.  42,  p.  110;  Von  Branian:  Arch,  fur  klin. 
Chir.,  1906,  vol.  81,  p.  351;  Lange:  Mlinch.  Med.  Wochenschrift,  1912,  p.  1421;  Tavlor: 
Am.  .Journ.  Med.  Sc,  1913,  vol.  146,  p.  836;  Fairbank:  Lancet,  1913,  1,  p.  1217; 
Thomas:  Annals  of  Surg.,  1914,  vol.  59,  p.  197;  and  a  number  of  articles  on  "Brachial 
birth  palsy"  and  "Erb's  paralysis." 


POSTERIOR  SUBLUXATIONS  OF  INFANCY.  691 

There  is  no  notable  preponderance  in  the  incidence  of  the  injury  on 
either  side,  and  it  is  occasionally  bilateral. 

The  mechanism  of  the  production  of  the  displacement  is  not  clear. 
The  usual  and  satisfactory  explanation  of  paralytic  dislocations  is 
found  in  the  loss  of  balance  between  the  opposing  muscles  that  move 
the  limb,  and  that  is  probably  true  in  a  measure  in  this  case.  The 
paralysis  of  the  spinati  clearly  causes  a  loss  of  support  at  the  back  of 
the  joint;  the  difficulty  is  to  determine  what  unopposed  muscles  move 
the  head  of  the  humerus  outward  and  backward  across  the  face  of  the 
glenoid.  The  unopposed  action  of  the  pectoralis  and  latissimus  and 
possibly  of  the  subscapularis  gives  the  inward  rotation,  and  the  weak- 
ening of  the  outer  portion  of  the  deltoid  allows  the  pectoralis  to  shorten 
and  limit  abduction.  The  resultant  attitude  favors  a  backward  dis- 
location ;  but  whence  comes  the  force  which  moves  the  humerus  outward 
and  backward?  In  one  reported  case  (Lewis)  the  mechanism  seems 
clear:  the  paralysis  was  noted  at  birth  and  the  limb  was  up  in  a  Velpeau 
dressing.  On  its  removal  the  displacement  was  noted.  I  imagine  the 
cause  to  have  been  the  upward  pressure  of  the  bandage  upon  the 
suitably  placed  limb,  and  am  disposed  to  seek  a  similar  external  cause 
or  adjuvant  in  other  cases.  Some  support  of  this  opinion  may  be 
found  in  the  fact  that  I  have  seen  the  same  group-paralysis  occur  at 
the  age  of  one  year  and  be  followed  not  by  a  posterior  displacement 
but  by  a  flail-joint. 

At  birth  the  limb  markedly  rotated  inward  hangs  limp  by  the  side, 
the  elbow  extended,  and  the  forearm  pronated.  In  60  per  cent,  of  the 
cases  (Fairbank)  the  paralysis  disappears  in  a  few  weeks  or  months, 
but  the  limb  will  then  be  found  to  have  taken  a  new  position,  the  arm 
directed  slightly  forward  and  outward,  the  elbow  flexed  at  about  100°, 
the  forearm  pronated  and  lying  across  the  abdomen.  The  head  of  the 
humerus  can  be  felt  and  often  plainly  seen  behind  its  proper  position, 
the  supra-  and  infra-spinatus  are  atrophied,  and  the  tendon  of  the 
pectoralis  is  rather  tense.  Often  the  scapula  and  humerus  are  dis- 
tinctly smaller  than  their  fellows.  Abduction  and  flexion  of  the  arm 
are  restricted,  extension  and  external  rotation  practically  lost. 

The  diagnosis  is  readily  made  by  recognition  of  the  position  of  the 
head  of  the  humerus,  and  its  paralytic  infantile  character  by  the 
attitude  and  restricted  movements  of  the  limb  and  the  possibly  per- 
sisting group-paralysis  or  paresis. 

The  treatment  varies  with  the  duration  of  the  displacement  and  the 
paralytic  conditions.  In  the  infant  and  with  the  paralysis  well  marked 
repair  of  the  injured  nerves  should  be  first  attempted.  Palpation, 
according  to  Dr.  Taylor,  will  almost  always  reveal  deep  influration 
on  the  side  of  the  neck  in  the  line  of  the  nerves  and  near  the  \ertebrcie. 
This  is  exposed  and  such  repair  of  the  constricted,  lacerated,  or  ruptured 
nerves  made  as  is  found  to  be  called  for  and  possible.^ 

1  For  details  and  after-treatment  see  A.  S.  Taylor,  Journal  of  the  American  Med. 
Assoc,  1907,  vol.  48,  p.  96  and  American  Journal  Med.  Sci.,  1913,  vol.  14(5,  p.  836. 


692  DISLOCATIONS. 

After  this  repair  of  the  nerve  has  been  made,  or  without  it  if  it  is 
deemed  unnecessary  or  inadvisable,  and  still  in  the  young  cases,  the 
head  of  the  humerus  should  be  forced  back  toward  or  into  the  glenoid 
fossa  if  practicable  by  forcible  pressure  upon  it  from  behind  while  the 
limb  is  abducted.  If  replacement  is  thus  effected  the  limb  should  be 
maintained  for  three  or  four  weeks  in  wide  abduction  by  a  suitable 
splint.  Fairbank  uses  a  broad  sheet  of  tin  half  encircling  the  chest 
close  below  the  axilla,  with  a  second  long  strip  soldered  to  the  centre 
of  its  upper  border  and  bent  to  pass  outward  under  the  arm  and  up 
along  the  back  of  the  forearm  flexed  at  a  right  angle. 

In  older  cases  in  which  reduction  cannot  be  made  various  operative 
measures  for  reduction  or  for  amelioration  of  the  position  have  been 
employed.  For  reduction  the  preference  appears  to  belong  to  an  anterior 
approach  through  the  interval  between  the  deltoid  and  pectoralis  with 
a  liberating  extension  outward  close  to  the  acromion.  After  division 
of  the  capsule  and  the  tendon  of  the  subscapularis  the  bone  can  be 
brought  into  place.  Occasionally  supplementary  division  of  tense 
bands  or  of  the  tendons  of  the  spinati  may  be  needed  to  give  full 
adduction. 

Marked  improvement  in  function  has  been  obtained  by  partial 
reduction  and  stretching  and  also  by  division  of  the  humerus  below 
the  insertion  of  the  deltoid  follov/ed  by  reunion  wdth  the  lower  segment 
rotated  outwardly  about  90°  (von  Braman). 


DISLOCATIONS  DUE  TO  PARALYSIS. 

Excluding  the  posterior  dislocations  of  infancy  above  described, 
these  are  not  numerous.  A  few  cases  have  been  reported  in  which, 
as  the  result  of  somewhat  extensive  paralysis  involving  the  muscles 
of  the  shoulder  the  humerus  has  sunk  an  inch  or  more  below  its  normal 
situation,  and  either  a  condition  of  flail-joint  has  been  established  or 
the  head  of  the  bone  has  assumed  a  more  or  less  fixed  position  on  the 
inner  side  of  the  edge  of  the  scapula,  below  the  coracoid. 

Occasionally  the  disability  of  the  muscles  is  due  to  a  traumatism 
(myopathic  dislocation).  In  a  case  reported  by  Wolff, ^  in  which  the 
head  of  the  humerus  had  sunk  almost  three  centimetres  below  the 
acromion,  and  the  disability  was  very  great,  the  functions  of  the  limb 
were  much  improved  by  an  operation;  the  joint  was  opened  posteriorly 
along  the  margin  of  the  glenoid  fossa,  the  articular  cartilage  removed, 
and  the  bones  fastened  together  with  silver  wire.  The  control  over  the 
limb  thus  obtained  through  the  scapula  was  such  that  it  could  be 
raised  and  lowered  and  even  a  little  adducted  and  abducted. 

1  Wolff:  Berl.  klin.  Wochcnschrift,  1SS6,  No.  52. 


PATHOLOGICAL   DISLOCATIONS  AND  SUBLUXATIONS.       693 

PATHOLOGICAL  DISLOCATIONS  AND  SUBLUXATIONS. 

Subluxation  or  complete  dislocation  may  be  made  easy  by  changes 
effected  in  the  articular  surfaces  or  the  capsule  b}'  disease,  or  by  paral- 
ysis of  the  deltoid  or  rotator  muscles  which  normally  aid  in  maintain- 
ing the  close  contact  between  the  bones.  The  reported  instances  are  not 
very  luunerous,  and  even  in  some  of  these  the  evidence,  clinical  or  post 
mortem,  has  left  not  only  the  character  and  extent  of  the  displacement 
in  doubt,  but  also  its  essential  cause.  Such  cases  do  duty  with  the 
different  writers  as  supposed  examples  of  widely  different  lesions,  such 
as  partial  traumatic  dislocations,  new  forms  of  dislocations,  and  chronic 
arthritis.  Gurlt^  gives  to  Adams  (Todd's  CyclopoBclia,  article  Shoulder- 
joint)  and  Canton  {London  Medical  Gazette,  1848,  vol.  vi,  p.  410,  and 
vol.  viii,  p.  Ill)  the  credit  of  having  first  shown  that  cases  described 
as  partial  dislocation  by  Sir  Astley  Cooper,  Hargrave,  and  others  were 
actually  examples  of  chronic  non-suppurative  arthritis.  In  his  o\mi 
description  of  the  changes  effected  by  this  disease  in  the  quoted  cases 
he  does  not  always  discriminate  between  those  which  were  the  effect  of 
the  prolonged  inflammation  and  those  which  should  probably  be  attrib- 
uted to  an  antecedent  traumatic  dislocation  which  originated  the  pro- 
cess such  as  rupture  of  the  tendons  of  the  supraspinatus  and  infra- 
spinatus and  subscapularis  muscles,  and  the  establishment  of  a  large 
opening  between  the  cavity  of  the  joint  and  the  subacromial  bursa.  A 
dislocation  recurring  after  such  injuries  should  be  classed  with  the 
"habitual  dislocations." 

Of  the  three  classes  made  by  Volkmann — dislocations  by  distention, 
by  destruction,  and  by  deformity  (see  Chapter  XXX^T) — the  second 
is  by  far  the  most  rare,  and  the  third  apparently  the  most  common, 
although  the  distinction  between  the  latter  and  the  first  cannot  always 
be  determined  clinically.  Indeed,  I  know  of  only  one  recorded  case 
in  which  the  history  clearly  shows  an  acute  non-traumatic  effusion  in 
the  joint  promptly  followed  by  an  abrupt  appearance  of  the  deformity 
with  instant  relief  of  the  pain,  such  as  has  been  observed  at  the  hip 
and  knee  in  the  course  of  acute  rheumatism  or  the  eruptive  fevers. 
The  case  was  reported  by  Hannon  and  is  quoted  by  IMalgaigne.^  A 
man  forty-five  years  old  who  had  previously  suffered  with  acute  rheu- 
matism in  the  knee  and  hip  became  feverish,  and  on  the  following  day 
had  an  acute  inflammation  of  the  shoulder-joint.  The  pain  increased 
and  on  the  night  between  the  fifth  and  sixth  days  became  suddenly- 
very  severe;  the  next  morning  a  subcoracoid  dislocation  was  found, 
and  was  reduced  with  some  relief  of  the  pain.  The  next  day  the  dis- 
location was  found  to  have  partially  recurred;  it  was  again  reduced, 
and  the  limb  fixed  with  a  bandage.    Recovery  followed. 

Malgaigne  thinks  the  over-distended  capsule  is  ruptured  on  the  inner 
side,  and  thus  the  dislocation  made  ])()ssil)le;  the  view  seems  insuffi- 
cient to  explain  the  easy  partial  recurrence.     When  the  efiusion  is 

1  Guilt:  Palholog.  Aniit.  dor  (.clciikiaiikheitcn,   1.S5.S,   p.  2')(). 

2  Malgaigne:  Loc.  fit.,  p.  5132. 

48 


694  DISLOCATIONS. 

more  slowly  produced  and  is  large  the  head  of  the  humerus  is  sepa- 
rated from  direct  contact  with  the  glenoid  cavity  by  a  layer  of  liquid, 
the  depth  of  which  may  amount  to  one  centimetre/  under  which  cir- 
cumstances it  is  evident  that  a  slight  force  would  be  sufficient  to  dis- 
place the  humerus  to  either  side  and  without  rupture  of  the  capsule, 
just  as  one  easily  produces  a  dislocation  in  a  freshly  dissected  shoulder 
after  making  a  small  opening  in  the  capsule  to  admit  the  air.  This 
requires  relaxation  of  the  scapular  muscles  which  normally  hold  the 
bones  close  together,  and  such  relaxation  would  not  be  found  when  the 
arthritis  is  acute  and  painful. 

A  class  of  cases,  of  which  quite  a  number  have  been  reported,  are 
sometimes  described  as  traumatic  dislocations  upward,  but  Malgaigne's 
opinion  that  they  are  the  result  of  arthritis  is  now  generally  accepted 
for  most  of  them.  They  are  characterized  by  the  projection  of  the 
head  upward  and  forward  and  rigidity  of  the  limb.  Malgaigne  quotes 
a  case  to  show  that  the  displacement  may  be  caused  by  carrying  the 
arm  in  a  sling  that  is  too  short  and  tight. 

Dr.  Ross^  reports  what  seems  to  be  a  clear  case  of  traumatic  sub- 
luxation forward,  reduced  under  ether,  and  Dr.  Brickner^  reports  one 
recent  case  and  two  in  which  some  weeks  had  elapsed  between  the 
supposed  cause  and  the  observation. 

Most  of  the  specimens  of  dislocations  hy  deformity  are  open  to  the 
doubt  whether  they  may  not  actually  be  nearthroses  following  trau- 
matic dislocations,  and  this  is  especially  true  of  those  in  which  the  dis- 
location is  forward.  Gurlt*  describes  seventeen  specimens  concerning 
which  this  doubt  exists,  and  I  think  he  might  well  have  added  to  them 
several  of  those  which  he  describes  as  examples  of  chronic  inflammation. 

1  Albert:   Chirurg.  und  Operat.,  vol.  ii,  p.  320. 

2  Ross:  Surg.,  Gyn.  and  Ob.,  February,  1909,  p.  168. 

3  Brickner:  Am.  Journ.  Surg.,  February,  1915. 

4  Gurlt:  Loc.  cit.,  p.  274. 


CHAPTER    XLV. 

DISLOCATIONS  OF  THE  ELBOW. 

A-natomy — Classification — Dislocations  of  Both  Bones  :  Backward,  lateral,  for- 
ward, divergent. 

Anatomy. 

On  either  side  of  the  lower  end  of  the  humerus  is  a  prominence, 
the  epicondyle,  which  can  be  easily  felt,  and  is  of  great  importance 
in  the  recognition  of  any  change  in  the  relations  of  the  bones  that 
constitute  the  elbow-joint.  The  inner  one,  commonly  called  the 
epitrochlea,  is  more  prominent  and  well-defined  than  the  outer  one, 
and  its  upper  margin  joins  the  shaft  of  the  humerus  by  a  sharp  curve, 
while  on  the  outer  side  of  the  shaft  the  supinator  ridge  connects  the 
side  of  the  shaft  with  the  epicondyle  by  a  gradual  slope.  Below  the 
epitrochlea  is  the  flattened  side  of  the  trochlea,  projecting  downward 
and  forward  about  half  an  inch,  with  a  sharp,  well-defined  margin 
which  is  masked  by  the  ulna  when  the  bones  are  in  place.  From  this 
edge  the  articular  surface  of  the  trochlea  passes  outward  like  a  cone, 
its  diameter  becoming  rapidly  smaller  for  about  half  an  inch,  and  then 
enlarges  again,  but  less  abruptly,  for  nearly  an  equal  distance.  Above 
it,  posteriorly,  is  a  deep  depression,  the  olecranon  fossa,  into  which  the 
tip  of  the  olecranon  is  received  in  full  extension  of  the  joint,  and  above 
it,  anteriorly,  is  a  corresponding,  smaller  one,  to  receive  the  tip  of  the 
coronoid  process  in  full  flexion.  On  the  outer  side  of  the  anterior  and 
lower  part  of  the  trochlea,  and  separated  from  it  by  a  shallow  vertical 
groove,  is  the  capitellum,  or  radial  head,  of  the  humerus  with  which 
the  head  of  the  radius  articulates,  a  rounded  prominence  looking 
directly  forward. 

The  ulna  articulates  with  the  trochlea  by  its  greater  sigmoid  cavity, 
which  has  a  central  longitudinal  ridge  fitting  into  the  central  depression 
of  the  trochlea,  and  opposing  displacement  to  either  side. 

The  radius  articulates  with  the  capitellum  by  the  slightly  concave, 
circular  upper  surface  of  its  cylindrical  head  and  with  the  lesser  sig- 
moid cavity  on  the  outer  side  of  the  ulna  and  coracoid  process  by  the 
side  of  its  head.  This  articular  surface  on  the  side  of  the  head  is  about 
three-eighths  of  an  inch  long  (from  above  downward)  on  the  inner  and 
posterior  side  of  the  bone,  the  part  that  is  in  contact  with  the  ulna  in 
supination,  but  is  shorter  on  the  outer  side  at  the  part  Avhich  comes  in 
contact  with  the  ulna  in  pronation. 

The  long  axis  of  the  troclilear  cones  and  the  ovoid  capitellum  coin- 
cide with  one  another  and  represent  the  axis  of  the  joint  for  flexion 
and  extension  ;  this  line  (crosses  the  lower  end  of  the  Innuerus  from  a 
point  just  below  and  in  front  of  the  external  e})ic(>ndyle  to  one  tliat  is 

(  G95  ) 


696 


DISLOCATIONS. 


Fig.  410 


just  covered  by  the  lower  part  of  the  epitrochlea,  and  is  inclined  down- 
ward and  inward  from  the  transverse  axis  of  the  lower  end  of  the 
humerus,  so  that  the  long  axis  of  the  forearm  does  not  coincide  with 
that  of  the  arm,  but  deviates  to  the  outer  side  as  it  passes  downward. 

When  the  bones  are  in  place  and  the  forearm  fully  extended  the 
uppermost  part  of  the  olecranon,  the  "  point  of  the  elbow,"  lies  on 
or  close  below  a  transverse  line  drawn  behind  the  limb  from  the  epi- 
trochlea to  the  epicondyle ;  and  when  the  elbow  is  flexed  at  a  right 
angle  the  same  point  lies  a  little  more  than  an  inch  directly  below  and 
nearly  midway  between  these  two  prominences  in  the  prolongation  of 
the  long  axis  of  the  shaft  of  the  humerus.  Ordinarily  the  relations 
of  these  three  points  to  one  another  can  be  readily  determined,  even 
when  the  region  is  swollen,  and  they    are    the  most  convenient  and 

trustworthy  aid  in  the  recognition 
of  the  existence  of  a  dislocation  of 
the  ulna. 

The  outer  border  of  the  head  of 
the  radius  can  be  felt  about  three- 
quarters  of  an  inch  below  the  epi- 
condyle in  a  line  drawn  from  the 
latter  to  the  wrist,  and  it  can  be 
felt  to  move  when  the  hand  is 
gently  rotated.  This  is  the  only 
point  where  the  interarticular  line 
is  distinctly  accessible  to  palpa- 
tion ;  at  all  other  points  it  is  too 
thickly  covered  by  soft  parts  or 
masked  by  the  parallelism  and 
close  contact  of  adjoining  surfaces. 
The  internal  lateral  ligament 
arises  above  from  the  anterior, 
lower,  and  posterior  portion  of  the 
epitrochlea  and  is  broadly  inserted 
below  along  the  inner  margin  of 
the  greater  sigmoid  cavity. 

The   external  lateral   ligament, 
shorter  and  narrower  than  the  in- 
The  bones  of  the  elbow:  b,  the  axis  of  motion,  ternal,  arises  above  just  below  the 

epicondyle  and  becomes  blended 
below  with  the  orbicular  ligament  that  surrounds  the  head  of  the 
radius,  some  of  its  posterior  fibres  being  continued  to  the  ulna. 

The  anterior  and  posterior  ligaments  are  thin  and  loose,  and  close  in 
the  joint  between  the  lateral  ligaments  in  front  and  behind,  respectively. 
The  orbicular,  or  annular,  ligament,  placed  like  a  ring  about  the 
head  of  the  radius  and  the  adjoining  portion  of  its  neck,  occupies 
three-fourths  of  a  circle  of  which  the  remaining  fourth  is  formed  by 
the  lesser  sigmoid  cavity  of  the  ulna  ;  it  is  thus  attached  by  its  two 
ends  to  the  ulna  and  encircles  the  head  of  the  radius.  It  is  reinforced 
externally  and  posteriorly  by  the  fibres  of  the  external  lateral  ligament. 
The  synovial  sac  extends  beyond  its   lower  border  for  a  short  distance 


DISLOCATIONS  OF  THE  ELBOW. 


G9- 


along  the  neck  of  the  radius,  and  is  then  reflected  upward  and  attached 
to  this  bone. 

The  uhiar  nerve  passes  close  behind  the  joint  on  the  inner  side 
between  the  olecranon  and  epitrochlea  in  close  relations  with  the  cap- 
sule and  lateral  ligament. 

Frequency. 

In  order  of  frequency  the  dislocations  of  the  elbow  come  next  after 
those  of  the  shoulder  and  fingers  (Chapter  XXVII.). 

Kronlein's  109  cases  arranged  according  to  age,  sex,  and  variety  are 
as  follows : 

Table  of  109  Dislocations  of  the  Elbow  (Kronlein), 


Sex. 

Age. 

Variety. 

M. 

F. 

1-10 

22 
9 

11-20 

44 
5 

21-30 

31-40 

41-50 

51-60 

61-70 

71-80 

Forearm,  backward 

Radius,  alone 

77 
9 

17 
6 

14 
1 

5 

4 

3 

1 

1 

This  shows  the  same  preponderance  in  males  over  females,  4  to  1, 
that  is  shown  by  dislocations  in  general,  and  that  the  great  majority, 
80  out  of  109,  occur  during  the  first  twenty-four  years  of  life.  Atten- 
tion was  called  in  Chapter  XLII.  to  the  difference  in  respect  of  age 
between  dislocations  of  the  elbow  and  those  of  the  shoulder,  the  latter 
being  rare  at  the  age  when  the  former  are  common,  and  most  frequent 
in  middle  life  ;  and  Kronlein's  opinion  was  there  quoted  that  fractures 
of  the  clavicle  are  in  childhood  the  equivalent  injury — that  is,  are  pro- 
duced by  the  same  cause — of  dislocations  of  the  shoulder  by  direct 
violence  in  middle  life,  and  that  dislocations  of  the  elbow  are  the 
equivalent  injury  of  dislocations  of  the  shoulder  by  indirect  violence. 
Another  possible  explanation  of  the  frequency  in  childhood  is,  I  think, 
the  hyperextension  of  the  joint  which  is  marked  at  that  age  and  is 
usually  wholly  lost  in  adult  life,  at  least  in  males. 


Classification. 

The  different  forms  of  dislocation  of  the  elbow  are  numerous,  for 
the  two  bones  of  the  forearm  may  be  displaced  together  in  any  one  of 
the  four  principal  directions,  or  each  may  take  a  different  direction,  or 
either  mav  be  dislocated  while  the  other  remains  in  place.  The  num- 
ber of  named  forms  has  been  still  further  increased  by  making  in  some 
a  distinction  between  ''  complete  "  and  "  incomplete  "  which  not  only 
is  not  justified  by  any  corresponding  important  pathological  or  clinical 
difference,  but  which  also  does  not  even  correspond  with  the  definition 
of  "incomplete"  given  by  those  who  make  most  use  of  the  term. 

Many  of  the  varieties  are  closely  allied  to  one  another,  and  produced 
by  causes  that  differ  very  slightly.  Thus,  if  the  joint  is  hyperextended, 
the  ligaments  torn,  and  a  backward  dislocation  of  both  bones  begun, 


Dislocations  of  the 
forearm    on    the  - 


698  DISLOCATIONS. 

the  final  position  taken  will  vary  with  the  direction  in  which  the  force 
continues  to  act,  and  with  the  addition  to  it  of  lateral  flexion  of  the 
joint  or  rotation  of  the  forearm,  so  that  forms  as  widely  different  in 
appearance  as  direct  backward  dislocation,  lateral  dislocation,  and  diver- 
gent dislocation  may  be  produced.  It  wall  be  proper,  therefore,  as 
well  as  convenient,  to  describe  under  the  more  common  type,  backward 
dislocation  of  both  bones,  much  that  concerns  many  of  the  other  forms, 
and  to  limit  the  descriptions  of  the  latter  mainly  to  the  points  of  differ- 
ence. 

The  classification  which  will  be  here  followed  is  the  same  in  its  prin- 
cipal features  as  those  adopted  by  most  recent  writers.  The  differences 
are  in  the  grouping  and  recognition  of  the  varieties. 

C  1.  Dislocations  backward, 

backward  and  outward, 
backward  and  inward. 

2.  Lateral  dislocations, 

1  ,      (  inward, 
incomplete  |  ^^.^^j.^, 

complete  outward. 

3.  Forward  dislocations, 
incomplete,  or  1st  degree, 
complete,  or  2d  degree, 
with  fracture  of  the  olecranon. 

4.  Divergent  dislocations, 
antero-posterior. 
transverse. 

f  1,  2.  Backward  and  /  1.  Incomplete,  or  1st  degree. 
Dislocations  of  the  J  upward,        \  2.  Complete,  or  2d  degree, 

ulna  alone,  |   3,   Backward  and  outward,  behind  radius. 

[  4.  Forward. 

f  1.  Backward. 

I    2.  Outward. 

\   3.  Forward. 

I   4.  By  elongation,  or  the  subluxation  of  children. 

L  5.  Associated  with  fracture  of  the  ulna. 

Congenital  and  pathological  dislocations, 

DISLOCATION    OF    THE   FOREARM    BACKWARD. 

This  is  the  most  common  of  all  dislocations  of  the  elbow.  It  is 
habitually  produced  by  a  fall,  but  although  the  examples  are  so  numer- 
ous the  mechanism  or  mode  of  production  has  been  the  subject  of  much 
controversy,  largely  due  to  the  resort  to  hypotheses  which  was  stimu- 
lated by  the  lack  of  definite  knowledge.  Few  who  fall  are  able  to 
descrilie  the  circumstances  of  the  fall,  to  say  whether  the  arm  was  fully 
extended  or  partly  flexed,  whether  the  violence  was  received  upon  the 
hand  or  upon  the  elbow,  and  a  preconceived  theory  in  the  mind  of  the 
surgeon  is  a  great  help  to  the  discovery  of  facts  that  favor  it. 

The  theory  of  production  by  forced  flexion  is  supported,  so  far  as  I 
know,  by  only  one  case,  and  that  a  case  that  has  only  recently  been 
reported.  Stetter^  had  a  patient  who,  while  working  in  a  mine,  was 
caught  under  a  falling  stone  in  such  a  way  that  his  left  elbow  was 

'  Stetter :  Compendium  der  Lehre  von  den  Luxationen,  1886,  p.  43. 


Dislocations  of  the 
radius  alone. 


sackwaud  dislocations  op  the  elbow.  699 

forcibly  flexed  between  the  stone  and  the  wall  and  was  dislocated  back- 
ward. When  seen,  about  an  hour  afterward,  the  joint  was  in  the  posi- 
tion of  extension.  Reduction  was  easily  effected  by  traction,  and 
recovery  took  place  Avithout  incident.  Fracture  of  the  coronoid  process 
could  not  be  recognized. 

The  theory  of  c/irfci  displacement  backward  ("glissement ")  formu- 
lated by  Boyer,  and  at  one  time  widely  held,  has  not  withstood  the 
criticism  of  later  writers  and  is  no  longer  accepted  in  explanation  of 
dislocations  caused  by  falls.  A  case  reported  by  Weber  nearly  fifty 
years  ago,  and  much  quoted  since,  is  an  example  of  production  in  this 
manner,  but  not  in  a  fall :  a  young  man,  wishing  to  show  his  strength, 
held  his  arm  extended  while  another  tried  to  bend  it ;  the  latter  not 
succeeding,  struck  the  front  of  the  upper  part  of  the  forearm  violently 
with  his  fist,  at  the  same  time  pressing  the  wrist  forward,  and  caused  a 
dislocation  which  could  not  be  reduced.  In  like  manner,  the  disloca- 
tion can  be  produced  by  a  blow  upon  the  back  of  the  arm  just  above  the 
elbow,  as  in  a  case  quoted  by  Malgaigne  from  Flaubert,  in  which  the 
patient's  arm  was  caught  under  an  overturned  wagon,  and  in  another 
seen  by  Hamilton.  A  similar  mechanism  has  also  been  observed  in 
outward  dislocation. 

The  theory  of  torsion  presented  by  Malgaigne,  according  to  which 
the  patient  in  his  fall  strikes  upon  the  inner  side  of  the  slightly  flexed 
forearm  and  the  elbow,  the  limb  being  somewhat  abducted,  is  perhaps 
true  of  some  cases.  Malgaigne's  explanation  is  very  brief;  he  simply 
says  the  dislocation  is  effected  by  "  a  movement  of  torsion  which  brings 
the  coronoid  process  successively  inward,  downward,  and  backward." 
However  obscure  the  explanation  may  be,  and  it  suggests  an  origin  in 
speculation  rather  than  in  observation,  the  fact  remains  that  in  a  few 
well-authenticated  cases  the  violence  has  certainly  been  received  upon 
the  upper  and  inner  part  of  the  forearm  and  not  npon  the  palm  of  the 
hand.  Pingaud  '  quotes  three  such  :  a  rider  falling  with  his  horse  and 
dislocating  his  elbow  while  the  hand  still  held  the  bridle  ;  a  man  falling 
in  the  gymnasium  with  his  forearm  bent  behind  his  back ;  another  fall- 
ing backward  and  rolling  upon  his  side  while  his  hand  held  his  cloak 
together  in  front  of  his  chest. 

Hyper  extension  and  Abduction.  It  is  now  generally  believed  that  the 
injury  is  habitually  caused  by  a  fall  upon  the  palm  of  the  outstretched 
hand,  the  elbow  being  in  comjjlete  extension,  and  that  the  j)riniary 
rupture  of  the  ligaments  which  makes  the  dislocation  possible  is 
efi^ected  by  hyperextension  of  the  joint.  That  this  was  a  ]iossible  cause 
was  known  to  Petit,  who  had  seen  a  compound  dislocation  thus  pro- 
duced ;  and  Desault  and  Bichat,  anticipating  in  this,  as  in  so  many 
other  things,  the  slower  judgment  of  the  profession,  declared  it  to  be 
the  common  mechanism,  but  the  investigations  which  first  satisfactorily 
demonstrated  it  were  made  by  a  young  German  surgeon  in  1844, 
Roser.^  His  results  were  quoted  and  his  experiments  repeated  and 
extended  toother  than  backward  dislocations  by  Streul)el,'^and  to  these 

^  Pingaud  :  Diet.  Eiicyclop.  dcs  Sc.  Mod.,  art.  Coudo,  p.  496. 
2  Roser:  Arch,  fiir  pliysioJoK.  Heilkiindo,  1S44,  Heft  2,  p.  185. 
'  Streubel  :  Frager  Viertcljahrschrift,  1850,  vol.  i.  p.  1. 


700  DISLOCATIONS. 

two  papers  and  the  articles  by  Denuee^  and  Pingaud,  above  men- 
tioned, the  reader  is  referred  for  details  to  which  space  cannot  here 
be  given. 

Experiment  upon  the  cadaver  shows  that  when  this  action,  of  a  fall 
upon  the  outstretched  hand,  is  imitated,  the  hand  being  supinated,  the 
anterior  portion  of  the  internal  lateral  ligament  becomes  tense  and  then 
yields,  usually  at  its  upper  insertion ;  then,  as  the  movement  is  con- 
tinued, the  rupture  extends  along  the  anterior  ligament,  perhaps 
involving  part  of  the  brachialis  anticus,  the  elbow  bends  inward,  and 
if  pressure  is  made  downward  upon  the  head  of  the  humerus  this  bone 
passes  down  in  front  of  the  coronoid  process  and  radius,  and  a  back- 
ward dislocation  is  produced. 

In  whatever  direction  the  force  may  act  it  is  evident  that  its  first 
effect  must  be  to  rupture  one  or  both  of  the  lateral  ligaments,  for  they 
are  the  ones  which  hold  the  bones  together  and  they  oppose  not  only 
lateral  motion  but  also  hyperextension.  According  as  one  or  the  other 
of  these  is  first,  or  alone,  torn,  and  according  to  the  direction  of  the 
force,  the  details  of  the  position  in  which  the  bones  come  to  rest  will 
vary  and  the  displacement  w^U  be  directly  backward  or  to  either  side 
or  with  more  or  less  abduction  or  adduction  of  the  forearm. 

The  frequency  with  which  the  tip,  or  more,  of  the  internal  epicon- 
dyle  is  broken  oiF  and  the  flexors  of  the  hand  detached  from  it  and  the 
adjoining  bone,  and  with  which  the  external  lateral  ligament  remains 
continous  with  the  periosteum  stripped  up  from  the  back  of  the 
external  condyle,  convinces  me  that  forcible  abduction  of  tlie  forearm, 
during  either  extension  or  partial  flexion  of  the  elbow,  is  the  first  step 
in  the  production  of  the  injury  in  a  large  number  of  cases  ;  this  breaks 
the  internal  lateral  ligament  and  frees  the  ulna,  and  then  the  bones  slip 
past  each  other,  the  external  lateral  ligament  being  torn  or  detached  in 
the  movement,  and  the  head  of  the  radius  tearing  off  the  corresponding 
portion  of  the  capsule  and  adjoining  periosteum  as  it  slips  up  behind 
the  condyle. 

The  cases  in  which  the  coronoid  process  and  the  portion  of  the  head 
of  the  radius  which  is  anterior  at  the  moment  are  broken  ofP  show  that 
in  them  the  direct  impulsion  of  the  bones  past  each  other  was  effected 
by  great  violence  acting  along  the  axis  of  the  forearm  before  these  two 
parts  had  entirely  cleared  the  lower  surface  of  the  humerus. 

In  one  case  that  came  under  my  observation  the  dislocation  M'as 
effected  by  hyperextension  and  torsion  without  the  aid  of  the  weight 
of  the  body  to  press  the  humerus  downward.  The  patient,  in  jumping 
down  from  his  wagon,  steadied  himself  by  grasping  the  rail  of  the 
seat,  and,  the  height  being  considerable,  the  wrench  was  sufficient  to 
dislocate  the  elbow. 

Pathology.  The  internal  lateral  ligament  is  always  torn,  usually  at 
its  insertion  upon  the  humerus,  and  the  rent  extends  along  the  anterior 
ligament.  The  external  lateral  ligament  is  usually  torn  or  detached 
from  the  humerus  ;  its  partial  preservation  in  some  cases  notably  affects 
the  attitude  of  the  limb  and  may  create  considerable  difficulty  in  reduc- 
tion.    The  orbicular  ligament  is  rarely  injured. 

*  Denuce:  Diet,  de  Med.  et  Chir.  prat.,  art.  Coude. 


SACK  WARD  DISLOCATIONS  OF  THE  ELBOW. 


701 


The  tip  of  the  internal  opicondyie  is  frequently  torn  off,  apparently 
by  avulsion  through  tlie  attached  flexor  muscles ;  when  the  fragment 


Fio.  411. 


Fig.  412. 


Figs.  411,  412.— Backward  dihlocatiun  nf  elbow. 


is  large  it  remains  attached  to  the  internal  lateral   ligament  and  is  dis- 
placed upward  and  backward. 

The  flexor  muscles  of  the  hand  are  sometimes  quite  freely  torn  from 


702  DISLOCATIONS. 

the  humerus,  the  brachialis  anticus  is  sometimes  lacerated  or  detached 
from  the  uhia,  with  or  without  the  corouoid  process ;  in  extreme  dis- 
placements this  muscle  may  be  torn  across  and  the  tendon  of  the  biceps 
may  slip  around  the  outer  side  of  the  external  condyle.  In  the  only 
case  in  which  I  have  seen  all  these  extensive  lesions  the  end  of  the 
humerus  was  stripped  of  all  its  muscles  and  had  passed  through  the 
fascia  and  lay  under  the  skin  in  the  fold  of  the  elbow,  but  the  patient 
had  been  subjected  to  three  attempts  by  different  surgeons  to  reduce 
under  ether,  and  the  lacerations  may  have  been  in  part  due  to  those 
attempts. 

The  capsule  at  the  back  of  the  external  condyle  is  torn  off  by  the 
edge  of  the  head  of  the  radius  and  seems  frequently  to  maintain  its 
continuity  with  the  adjoining  periosteum,  which  latter  is  stripped  up 
for  some  distance  and  caps  the  head  of  the  radius  in  its  new  position. 
This  stripping  up  of  the  periosteum  and  its  effect  in  producing  new 
bone  if  the  dislocation  remains  unreduced,  which  I  pointed  out  in  the 
first  edition,  I  have  repeatedly  observed  since.  (See  Chapter  XLYII.) 
The  anterior  portion  of  the  capsule  may  be  variously  torn  or  detached 
at  either  its  upper  or  lower  insertion. 

The  displacement  of  the  bone  varies  greatly,  both  in  extent  and  in 
direction.  The  top  of  the  coronoid  process  may  rest  against  the  lo\ver 
and  posterior  surface  of  the  trochlea,  and  the  radius  still  remain  in 
contact  with  the  under  surface  of  the  capitellura  by  the  anterior  por- 
tion of  its  disk,  or  the  latter  may  be  entirely  dislocated  and  rest  against 
the  posterior  face  of  the  external  condyle. 

When  the  ulna  is  more  and  the  radius  less  displaced  the  deviation  of 
the  wrist  is  to  the  inner  side  ;  and  when  both  bones  are  completely  dis- 
placed backward  deviation  of  the  wrist  to  either  side  will  incline  their 
upper  ends  to  the  opposite  side,  and  thus  bring  them  nearer  to  the 
internal  or  the  external  epicondyle  respectively. 

If,  in  the  production  of  the  dislocation,  the  lateral  outward  flexion 
is  more  marked  than  the  liyperextension,  the  capitellum  slips  along 
the  head  of  the  radius  to  its  inner  side,  and  the  latter  lodges  on  the 
outer  surface  of  the  former  just  below  the  epicondyle,  while  the  coro- 
noid process  rests  against  the  posterior  surface  of  the  external  condyle, 
having  been  carried  outward  by  pronation  of  the  forearm.  The  long 
axis  of  the  forearm  is  deviated  to  the  inner  or  the  outer  side  ;  the 
internal  lateral  ligament  is  freely  torn.  This  is  the  dislocation  back- 
ward and  outward^  classed  by  some  with  the  outward,  by  others  with 
the  backward  dislocations,  and  sometimes  misleadingly  reported  as  a 
pure  outward  dislocation. 

Complications.  Fractures  of  the  olecranon,  the  coronoid  process,  the 
head,  sliaft,  and  lower  extremity  of  the  radius,  and  the  epitrochlea  have 
been  observed  in  connection  with  dislocation  backward.  For  fracture 
of  either  condyle  with  dislocation  from  the  other  see  Chapter  XIX. 
Fracture  of  the  olecranon  is  effected,  presumably,  by  tiie  pressure  of  its 
tip  against  the  back  of  the  humerus  when  the  posterior  part  of  the 
lateral  ligament  proves  stronger  than  the  bone,  and  a  fracture  is  pro- 
duced with  angular  deformity  and  crushing  of  the  posterior  portion  of 
the  bone  at  the  seat  of  fracture. 


SACK  WARD  DISLOCATIONS  OF  THE  ELBOW.  703 

Fracture  of  the  coronoid  process  is  probably  liroduced  when  the 
momentum  oif  the  fall  forces  the  humerus  downward  before  the  hyper- 
extension  has  quite  carried  the  tip  of  the  process  past  the  trochlea;  and 
Lotzbeck's  experiments  indicate  that  it  can  also  be  caused,  when  the 
elbow  is  slightly  flexed,  by  the  direct  impulsion  of  the  lower  end  of 
the  humerus  in  a  direction  parallel  to  that  of  the  long  axis  of  the 
forearm.  As  the  brachialis  anticus  is  attached,  not  to  the  tip  of  the 
process,  but  to  its  anterior  face  and  the  adjoining  surface  of  the  ulna, 
the  displacement  of  the  fragment  is  usually  slight. 

Partial  fracture  of  the  head  of  the  radius  has  been  observed  in  a 
number  of  cases,  often  associated  with  fracture  of  the  coronoid  process. 
It  has  been  described  in  Chapter  XX.  The  portion  broken  off  is  the 
anterior  or  inner  third,  and  the  fracture  is  effected  by  the  direct  press- 
ure of  the  condyle  brought  to  bear  upon  the  periphery  of  the  disk  by 
the  displacement  backward  of  the  latter. 

One  case  of  fracture  of  the  shaft  of  the  radius  and  three  of  fracture 
of  its  lower  end,  Colles's  fracture,  complicating  backward  dislocation 
•of  the  elbow,  are  reported  in  a  thesis  by  Dupuy.^ 

The  dislocation  may  be  made  compound  by  the  projection  of  the 
trochlea  through  the  skin  in  the  fold  of  the  elbow,  and  the  brachial 
artery  (p.  496),  and  the  median  nerve,  may  be  ruptured.  In  a  case 
reported  by  Ledderhose,^  in  which  the  dislocation  was  made  compound 
by  a  transverse  wound  in  the  fold  of  the  elbow,  the  musculo-spiral 
nerve  was  torn.  Five  months  later  the  nerve  was  successfully  reunited 
by  suture. 

In  another,  reported  by  Ferret,'  the  median  nerve,  exposed  for  more 
than  three  inches  in  the  wound  and  tightly  stretched,  sloughed. 

Symptoms.  The  elbow  is  usually  flexed  at  an  angle  about  midway 
between  complete  extension  and  flexion  at  a  right  angle,  but  it  may  be 
completely  extended,  or  even  hyperextended,  as  in  a  case  reported  by 
Morel-Laval  lee.*  The  limb  is  shortened,  and  if  viewed  from  behind 
the  shortening  appears  to  be  in  the  arm,  because  of  the  elevation  of 
the  olecranon,  but  if  viewed  from  in  front  in  the  forearm.  If  a  few 
hours  have  passed  since  the  injury  was  received,  the  region  of  the 
elbow  is  occupied  by  a  swelling  which  may  be  so  great  as  completely 
to  mask  the  bony  points  and  the  characteristic  changes  in  outline ;  but 
if  this  swelling  is  slight  or  absent  the  antero-posterior  diameter  of  the 
joint  appears  increased,  and  the  transverse  diameter  unchanged.  The 
lower  part  of  the  triceps  curves  backward  in  the  median  line  to  the 
end  of  the  olecranon,  creating  a  hollow  on  either  side,  in  the  outer  one 
of  which  may  be  seen  a  slight  elevation  marking  the  position  of  the 
liead  of  the  radius. 

The  front  of  the  joint  appears  full,  and  the  forearm  just  below  it  is 
broadened  by  the  shortening  of  the  nniscles  that  arise  from  either  con- 
dyle. Sometimes  the  outline  of  the  trochlea  can  be  distinctly  felt  or 
even  seen,  but  ordinarily  it  is  masked  by  the  overlying  nuisolcs. 

The  forearm  may  take  any  attitude  between  j)ronation  and  siipina- 

1  Diipuy  :  Those  de  Paris,  18S2,  No.  151. 

2  Tvcdderhose :  Deutsche  Zeitschrift  fiir  ('liinirf,Me.  vol.  xxv.  p.  2.'{H,  :il)stract  iii  ("eu- 
tralblatt  fiir  Chirur^ie,  1HH7,  p.  732, 

'  Ferret:  ProRres  Medical,  May  7,  1HH7. 

*  Morel-Lavallee :  Bull,  de  la  Soc.  de  Chir.,  1856,  vol.  vii.  p.  9. 


704 


DISLOCATIONS. 


Fig.  413. 


tion,  for,  as  voluntary  rotation  is  possible,  the  patient  places  it  in  the 
most  convenient  attitude.  The  axis  of  the  forearm  may  be  deviated 
to  either  side. 

Flexion  and  extension  are  possible  within  variable,  but  always  nar- 
row, limits  and  painful ;  and  when  flexion  is  made  the  prominence  of 
the  olecranon  behind  the  joint  is  increased.  Abnormal  lateral  mobility 
of  the  joint  exists. 

If  now  the  positions  of  the  two  epicondyles  and  the  tuberosity  of 
the  olecranon  can  be  recognized,  it  will  be  seen  that  the  latter  is  dis- 
placed backward  and  upward,  rising,  if  the 
limb  is  extended,  above  the  horizontal  line 
joining  the  epicondyles,  or  projecting  far 
behind  a  frontal  plane  passing  through 
these  two  points  if  the  limb  is  partly 
flexed.  This  backward  projection  of  the 
olecranon  will  be  increased  by  flexion  of 
the  elbow,  and  at  the  same  time  it  will 
descend ;  while  by  extension  it  will  be 
moved  to  a  higher  level  and  brought  nearer 
the  back  of  the  humerus. 

The  head  of  the  radius  can  be  felt,  per- 
haps even  seen,  under  the  skin  below  and 
to  the  outer  side  of  the  olecranon  close 
behind  the  external  condyle,  and  can  be 
recognized  by  the  concavity  of  its  upper 
surface  and  felt  to  move  under  the  finger 
when  the  wrist  is  gently  rotated. 

On  the  inner  side,  if  the  swelling  is  not 
too  great,  the  finger  passing  forward  and 
downward  from  the  tip  of  the  olecranon 
successively  recognizes  the  curved  inner 
margin  of  the  great  sigmoid  cavity,  possi- 
bly also  the  coronoid  process  and  the  back 
of  the  trochlea,  and  then  moving  around  the  inner  side  below  the 
epitrochlea  to  the  front  may  trace  the  sharp  circular  margin  of  the 
trochlea  and  recognize  its  rounded  surface  and  groove  in  front. 

Diagnosis.  The  diagnosis  should  be  made  upon  actual  recognition 
by  palpation  of  the  position  of  the  two  epicondyles,  the  olecranon,  and 
the  head  of  the  radius.  The  surgeon  should  never  be  satisfied  with 
less  than  that,  and  if  it  cannot  be  obtained  he  should  refuse  to  make 
a  positive  diagnosis.  jSTo  attitude  of  the  limb,  no  measurements,  no 
apparent  ciianges  in  its  diameter,  no  considerations  of  abnormal 
mobility  or  fixation  are  sufficient,  and  the  surgeon  who  trusts  to  them 
will  be  only  too  likely  to  add  to  the  already  too  long  series  of  limbs 
crippled  in  consequence  of  errors  in  diagnosis. 

Of  the  different  fractures  that  have  been  mentioned  as  complica- 
tions, those  of  the  olecranon  and  epitrochlea  are  easily  recognized  by 
manipulation ;  that  of  the  coronoid  process  is  indicated  by  easy  recur- 
rence of  the  dislocation  after  its  reduction,  but  if  the  patient  is  ether- 
ized at  the  time  this  symptom  is  by  no  means  characteristic,  and,  fur- 


L»islocatioii  ol  the  elbow  backward. 


BACKWARD  DISLOCATIONS  OF  THE  ELBOW. 


ro5 


thermore,  it  is  also  present  in  those  fractures  of  the  internal  condyle 
which  are  complicated  by  displacement  of  the  fragment  and  disloca- 
tion of  the  radius  backward.  Fracture  of  the  head  of  the  radius  can 
hardly  be  recognized  unless  the  fragment  should  be  so  displaced  that 
it  can  be  felt  on  the  outer  side  of  the  condyle. 

The  records  of  discussions  over  cases  presented  to  the  various  learned 
societies  show  very  clearly  the  difficulty  of  making  a  diagnosis  in  cases 
that  have  remained  unreduced  for  any  length  of  time,  especially  in 
children  in  whom  the  injured  or  stripped-up  periosteum  rapidly  forms 
new  bone  which  obscures  the  original  outlines.  Much  of  the  uncertainty 
concerning  the  character  and  results  of  reported  cases  is  due  to  this  fact. 

Prognosis.  The  prognosis  is  favorable;  reduction  in  recent  cases  may 
be  confidently  expected,  with  complete  or  almost  complete  restoration 
of  function.     In  old  cases,  of  more  than  six  weeks'  standing,  the  prob- 

FiG.  414. 


Myositis  ossificans  after  dislocation  of  the  elbow. 

ability  of  reduction  is  greatly  diminished,  although  successes  have  been 
reported  after  three,  five,  and  even  seven  months.  The  greater  the 
displacement  upward,  the  arm  being  only  slightly  flexed,  the  less  is  the 
probability  of  reduction  after  the  lapse  of  some  time,  for  the  lacerated 
lateral  ligaments  have  then  formed  new  attachments  at  points  so  high 
on  the  humerus  that  they  must  be  again  ruptured  before  the  ulna  and 
radius  can  be  brought  below  the  end  of  the  humerus,  and  in  attempting 
to  rupture  them  by  flexing  the  elbow  the  olecranon  or  trochlea  may  be 
broken.  In  addition,  the  sigmoid  cavity  fills  up  with  fibrous  tissue 
which  obliterates  its  articular  surface  and  binds  it  to  the  back  of  the 
humerus.  Furthermore,  as  the  injury  is  most  frecjuent  in  the  young, 
whose  periosteum  is  active  to  firoducc  bone  when  irritated  or  stripped 
up,  obstacles  may  soon  be  created  w  liidi  cannot  be  overcome  except  by 


706  DISLOCATIONS. 

arthrotomy.  In  some  cases  of  unreduced  dislocation  the  patients  have 
in  time  obtained  a  free  range  of  motion  and  a  useful  limb,  but  usually 
the  mobility  is  very  slight.  In  a  discussion  upon  the  subject  in  the 
Societe  de  Chirurgie  (Bulletins,  1861,  p.  103),  it  was  stated  as  the 
experience  of  several  of  the  members  that,  in  the  older  cases  at  least, 
it  was  not  uncommon  to  fail  to  make  a  complete  reduction  of  the 
radius,  but  that  nevertheless  the  patients  recovered  full  use  of  the  joint. 
Recurrence  of  the  dislocation  of  the  radius  alone  has  also  been  observed.^ 

Even  after  an  early  reduction  the  mobility  may  be  diminished  by 
the  results  of  the  arthritis,  especially  in  the  old  and  rheumatic,  or  by 
new  formations  of  bone  about  the  joint  which  mechanically  limit  its 
range  of  motion,  or,  very  exceptionally,  by  an  ossifying  myositis  of  the 
brachialis  anticus.^ 

Machol  ^  observed  this  myositis  in  sixteen  consecutive  cases.  He  ex- 
amined them  all  carefully  with  the  aid  of  the  .T-rays.  The  lump  ap- 
peared about  the  end  of  the  first  month,  increased  through  the  third 
month,  and  then  diminished  in  size  and  grew  harder.  In  some  a  bony 
connection  appeared  to  form  between  the  lump  and  the  humerus,  and  in 
tiiese  the  interference  with  function  persisted  ;  but  in  most  no  such 
connection  appeared,  function  improved,  and  the  lump  gradually  dis- 
appeared.    Franzenheim  *  says  the  tumor  may  reappear  after  removal. 

Compound  dislocations  usually  do  well  if  kept  surgically  clean  and 
well  drained,  and  the  limb  suspended  ,  primary  resection,  in  the  ab- 
sence of  special  indications,  should  not  be  done. 

Treatment.  Much  less  attention  has  been  paid  in  the  treatment  of 
dislocations  backward  of  the  elbow  to  the  obstacles  created  by  the 
untorn  ligaments  than  in  those  of  the  shoulder  or  hip,  and  methods 
are  in  general  and  successful  use  that  are  directly  opposed  in  character 
to  those  based  upon  a  consideration  of  such  obstacles  and  upon  the 
principle  that  a  dislocated  bone  should  be  returned  along  the  route  by 
which  it  has  been  displaced.  The  explanation  of  this  success  of  faulty 
methods  is  to  be  found  either  in  an  extensive  primary  laceration  of 
both  lateral  ligaments  or  in  the  possible  overcoming  of  the  obstacles 
by  increasing  the  laceration.  The  easy  reduction  of  most  dislocations 
under  ether  by  direct  pressure  in  suitable  directions  upon  the  projecting 
ends  of  the  bones  is  an  indication  that  ligamentous  obstacles  of  impor- 
tance do  not  exist  and  that  the  chief  opposition  is  furnished  by  the 
muscles  spasmodically  contracted  on  all  sides  of  the  joint,  and  the 
inference  is  too  often  drawn  that,  provided  this  opposition  is  overcome 
by  force  or  by  anaesthesia,  the  surgeon  need  not  particularly  concern 
himself  with  the  attitude  of  the  limb  during  his  efforts  to  reduce. 
But  the  success  of  a  faulty  method  should  not  make  us  unmindful  of 
its  defects ;  our  work  should  be  done  skilfully,  as  Mell  as  successfully, 
and  even  if  our  errors  M^ill  pass  undetected  and  their  consequences  be 
promptly  repaired,  we  should  not  lightly  commit  them. 

Such  a  generally  successful  but  faulty  method  is  that  in  which  the 

'  Mason  :  New  York  Medical  Record,  1880,  vol.  xix.  p.  398. 

*  Mvsch :  Deutsche  Zdtschrift  fiir  Chir.,  1899,  vol.  liv  p.  207;  Sudeck :  Beilage  zuui 
Centralblatt  fur  Chir.,  1901,  p.  1.37. 

3  Machol  :   BeitriiKe  ziir  klin.  Chir.,  vol.  Ivi.  p.  77.">. 

*  Franzenheim  .  Deutsche  Med.  Wochen.schi  ift,  190s,  No.  12. 


BACKWARD  DISLOCATIONS  OF  THE  ELBOW. 


JO', 


forearm  is  flexed  as  nearly  as  possil)le  to  a  right  angle,  dra^n  directly 
away  from  the  humerus  in  the  direction  of  the  long  axis  of  the  latter 
until  the  tip  of  the  coronoid  process  is  brought  below  the  trochlea,  and 
then,  the  traction  being  relaxed,  is  moved  forward  and  upAvard  into 
place.  Many  different  methods  of  effecting  this  manoeuvre  have  been 
employed,  the  one  commonly  known  as  Sir  Astley  Cooper's,  although 
practised  in  exactly  the  same  manner  long  before  his  time,  in  which  the 
surgeon's  knee  is  placed  in  the  bend  of  the  elbow,  being  the  most  com- 
mon. Cooper's  description  of  it  is  as  follows  :^  "  The  patient  is  made  to 
sit  down  upon  a  chair,  and  the  surgeon,  placing  his  knee  on  the  inner  side 
of  the  elbow-joint,  in  the  bend  of  the  arm,  takes  hold  of  the  patient's 
wrist,  and  bends  the  arm.  At  the  same  time  he  presses  on  the  radius 
and  ulna  witli  his  knee,  so  as  to  separate  them  from  the  os  humeri,  and 
thus  the  coronoid   process  is   thrown  from  the  posterior  fossa  of  tlie 

Fifi  415. 


Reduction  of  backward  dislocation  of  the  elbow  in  hyporexlension. 


humerus  ;  and  whilst  this  pressure  is  supjiorted  by  the  knee  the  arm 
is  to  be  forcibly  but  slowly  bent,  and  the  reduction  is  soon  effected. 
It  may  also  be  accomplished  by  placing  the  arm  around  the  post  of  a 
bed,  and  by  forcibly  bending  it  while  it  is  thus  confined." 

The  knee  is  thus  used  as  the  fulcrum  of  a  lever  of  which  the  wrist 
is  at  the  end  of  the  long  arm,  and  the  olecranon  at  that  of  the  short 
one.  The  resistance  to  be  overcome  is  that  of  the  muscles  and  of  the 
soft  parts  which  bind  the  ulna  and  radius  to  the  humerus,  and  it  must 
be  overcome  to  an  extent  that  will  allow  the  ulna  to  be  directly  sepa- 
rated from  the  lower  border  of  the  humerus  to  a  distance  equal  to  the 
height  of  the  coronoid  process,  more  than  half  an  inch  ;  the  lateral 
ligaments,  the  upper  fibres  of  the  anconaMis,  and  the  stout  fascia  on  the 

'  Cooper.   Loc   cit.,  ])   :582. 


708  DISL  0  CA  TIONS. 

outer  side  of  the  elbow,  must  all  yield  to  this  extent.  That  they  com- 
monly do  so  is  a  proof  of  the  amount  of  the  laceration  and  of  the 
force  employed.  The  method  is  faulty  because  it  requires  for  its 
accomplishment  a  maximum  of  laceration  on  both  sides  of  the  joint 
which  may  have,  and  probably  has,  been  escaped  in  the  original  injury, 
and  because  it  requires  the  simultaneous  elongation  of  the  muscles  of 
the  front  and  back  of  the  arm.  Possibly  forcible  pronation  of  the 
upper  part  of  the  forearm,  facilitated  by  the  rupture  of  the  internal 
lateral  ligament,  would  make  it  easier  thus  to  disengage  the  coronoid 
process  and  avoid  additional  laceration  on  the  outer  side. 

The  specific  objection  made  to  this  method  applies  equally  to  all  in 
which  reduction  is  made  while  the  elbow  is  flexed  at  a  right  angle,  and 
in  a  less  degree  to  those  in  which  the  joint  is  partly  flexed.  In  the 
latter  the  modes  of  application  of  the  force  are  numerous  and  varied  : 
traction  by  pulleys,  by  the  hand,  or  by  a  loop  placed  above  the  olecra- 
non, and  pressure  by  the  thumbs  upon  the  olecranon  and  head  of  the 
radius  while  the  fingers  are  interlocked  in  front  of  the  lower  end  of 
the  humerus.  Tlie  more  extended  the  limb  the  more  easily  will 
metliods  of  this  kind  succeed,  but  they  need  to  be  supplemented  by 
flexion  or  direct  coaptation  after  the  coronoid  process  has  been  brought 
sufficiently  low. 

A  possible  obstacle  in  the  way  of  traction  in  the  extended  or  slightly 
flexed  position  is  the  engagement  of  the  tip  of  the  coronoid  process  in 
the  olecranon  fossa  of  the  humerus  in  sucli  a  way  that  its  under  sur- 
face rests  directly  against  the  upper  posterior  portion  of  the  trochlea 
and  prevents  the  ulna  from  moving  bodily  in  the  direction  of  its  long 
axis.  It  can  be  disengaged  by  pronating  the  upper  part  of  the  fore- 
arm, hyperextending  the  elbow,  or  pressing  the  upper  part  of  the 
forearm  backward  and  the  lower  part  of  the  arm  forward.  Except 
for  this  possible  obstacle  traction  in  complete  extension  meets  the  indi- 
cations sufficiently  and  without  needless  increase  of  the  laceration,  and 
the  obstacle  can  be  readily  overcome,  as  has  just  been  said,  by  slight 
hyperextension  as  suggested  by  Roser  in  1844. 

Traction  may  be  made  by  the  hands  of  the  surgeon  himself,  or  by 
assistants  while  the  surgeon  watches  the  descent  of  the  ulna,  frees  the 
coronoid  process  if  necessary,  and  presses  the  radius  and  ulna  forward 
into  {)lace  at  the  proper  time  ;  or  it  may  be  made  by  an  India-rubber  cord 
or  by  fastening  a  weight  to  the  wrist  and  allowing  the  arm  to  hang  down. 

This  method,  traction  upon  the  fully  extended  or  even  hyperextended 
forearm,  followed  by  direct  pressure  forward  on  the  upper  ends  of  the 
ulna  and  radius  and  counter-pressure  backward  on  the  lower  end  of 
the  humerus,  or  simply  by  flexion,  corresponds  as  nearly  to  the  funda- 
mental principle  of  reduction  as  is  practicable  in  the  usual  uncertainty 
as  to  the  exact  attitude  taken  by  the  limb  at  the  moment  of  dislocation. 

In  all  cases  of  doubt  or  difficulty  anaesthesia  should  be  used  ;  and,  as 
a  general  rule,  whenever  a  lateral  displacement  is  associated  witli  the 
backward  one  the  bones  should  be  pressed  sideways  into  line  before 
tliey  are  drawn  downward. 

When  the  lateral  element  of  the  displacement  is  very  marked  and  it 


BACKWARD   DISLOCATIOXS  OF  THE  ELBOW.  709 

is  probable  that  the  primary  dislocation  was  directly  outward  and  has 
been  followed  by  a  consecutive  displacement  backward,  anaesthesia 
should  not  be  omitted,  and  after  full  relaxation  has  been  obtained  the 
first  attempt  should  be  to  move  the  olecranon  and  head  of  the  radius  to 
the  radial  side  of  the  humerus  and  transform  the  dislocation  into  a  pure 
outward  one.  By  so  doing  the  principle  of  replacing  the  bones  by  the 
route  along  which  they  have  been  displaced  is  followed,  and  the  risk 
of  engaging  the  tendon  of  the  biceps  behind  the  external  condvle  is 
avoided.  (See  also  the  following  section.)  If  the  attempt,  cautiously 
made,  does  not  succeed,  the  surgeon  should  next  seek  to  change  the 
displacement  into  a  pure  backward  one  and  reduce  as  before  descrii^ed. 

If  some  time  has  elapsed  since  the  accident,  more  than  ten  or  fifteen 
days,  it  may  be  desirable  to  break  up  such  adhesions  as  have  formed 
by  flexion,  extension,  and  lateral  flexion,  but  it  must  be  borne  in  mind 
that  forced  flexion  always  carries  the  risk  of  fracturing  the  olecranon. 
This  is  sometimes  intentionally  done  to  facilitate  reduction  in  old  cases  ; 
it  is  of  course  followed  by  more  or  less  loss  of  the  power  of  active 
extension.     The  trochlea  also  has  been  thus  broken. 

Fracture  of  the  coronoid  process  requires  no  special  treatment ;  appar- 
ently the  fragment  is  seldom,  if  ever,  much  displaced,  for  it  retains  its 
connection  with  the  capsule  and,  after  reduction,  is  steadied  between 
the  lower  end  of  the  humerus  and  the  tendon  of  the  brachialis  anticus. 
The  special  indication  arising  from  it  is  to  guard  against  a  recurrence 
of  the  dislocation,  which  is  best  done  by  keeping  the  elbow  flexed  at 
or  even  within  a  right  angle.  A  posterior  moulded  splint  is  an  addi- 
tional safeguard. 

Fracture  of  the  olecranon  requires  the  special  treatment  ])roper  to 
that  injury,  but  as  the  extended  position  of  the  joint,  which  is  most 
favorable  for  the  prompt  and  close  repair  of  the  fracture,  exposes  to  a 
partial  or  even  complete  recurrence  of  the  dislocation,  it  must  be  avoided 
until  after  the  rupture  of  the  lateral  ligaments  has  been  in  great  part 
repaired.  If,  in  the  flexed  position,  the  olecranon  is  separated  from 
the  ulna  it  should  be  drawn  down  and  held  in  contact  by  adhesive 
plaster,  or  the  fracture  should  be  exposed  and  the  fragments  sutured. 

Fracture  of  the  head  of  the  radius  requires  jirolonged  rest  of  the 
joint,  with  a  view  to  reunion  if  the  fragment  remains  in  place  ;  if 
displaced  and  readily  accessible  the  fragment  should  be  removed.  If 
the  fragment  should  remain  on  the  inner  side  of  the  joint,  between  the 
radius  and  ulna,  it  would  be  most  easily  reached  through  an  anterior 
incision,  in  making  which,  however,  special  care  would  have  to  be 
taken  to  avoid  injury  to  the  musculo-spiral  nerve  and  its  two  branches, 
the  radial  and  posterior  interosseous.  In  one  case  I  operated  a  month 
after  the  accident,  because  of  stiffness  of  the  joint,  and  found  a  small 
piece  of  the  head  displaced  to  the  front  of  the  neck  and  united  there. 
I  removed  it  and  all  adhesions  and  covered  the  raw  surfaces  with  silver 
foil  in  the  hope  of  preventing  fresh  adhesion.  Two-thirds  of  the  rota- 
tion was  preserved. 

Fracture  of  the  epitrochlea  requires  that  the  muscles  of  the  forearm 
that  arise  from  this  prominence  should  be  kept  relaxed. 
49 


710  DISLOCATIONS. 

If  the  dislocation  is  compound,  but  without  laceration  of  the  soft 
parts  so  extensive  as  to  make  amputation  unavoidable,  the  parts  must 
be  thoroughly  cleansed  and  replaced,  efficient  drainage  provided  through 
the  wound  or  through  counter-openings,  and  the  limb  immobilized  in 
a  plaster  splint  and  suspended.  Some,  perhaps  extensive,  suppuration 
is  probable  in  the  soft  parts,  but  the  joint  is  likely  to  escape  so  far  as 
to  preserve  a  fair  amount  of  motion.  Even  if  the  brachial  artery  is 
torn  the  limb  may  still  be  saved ;  and  although  the  additional  compli- 
cation of  rupture  of  the  median  nerve  has  been  thought  to  make 
amputation  necessary,  I  think  a  different  view  would  now  be  taken 
and  the  attempt  would  be  made  to  reunite  its  ends.  Fortunately 
both  complications,  especially  the  latter,  are  very  rare. 

After-treatment.  In  uncomplicated  cases  it  is  necessary  only  to 
retain  the  limb  in  a  sling  for  two  or  three  weeks,  or  until  such  time  as 
the  dependent  position  does  not  cause  pain.  Passive  motion,  to  prevent 
anchylosis,  is  not  necessary,  and  is  actually  harmful  during  the  first 
fortnight  if  it  causes  pain.  The  limb  may  safely  be  immobilized  until 
the  injury  to  the  capsule  and  ligaments  shall  have  been  repaired.  It 
will  be  more  or  less  stiff  when  first  taken  out  of  the  dressings,  but  com- 
plete restoration  of  rts  functions  may  be  confidently  expected  under  daily 
use.  Exceptions  to  this  complete  recovery  are  sometimes  found  in  the 
old  and  rheumatic,  in  complicated  cases,  and  in  the  young  if  the  peri- 
osteum has  been  extensively  stripped  up.  In  the  first  class,  the  old 
and  rheumatic,  gentle  passive  motion  strictly  confined  within  the  limits 
beyond  which  persistent  pain  and  tenderness  are  caused,  may  be  of 
service  to  diminish  the  subsequent  stiffness  and  hasten  its  disappear- 
ance, and  in  all  it  may  be  useful  to  change  every  day  or  two  the  angle 
at  which  the  limb  is  immobilized. 


LATERAL    DISLOCATIONS    OF    THE   FOREARM. 

Both  bones  of  the  forearm  may  be  together  dislocated  to  the  inner 
or  to  the  outer  side,  and  the  dislocation  may  be  complete  or  incom- 
plete. In  the  incomplete  form,  in  the  sense  in  which  the  term  has 
been  generally,  and  will  here  be,  used,  one  of  the  two  bones  still 
remains  below  or  in  front  of  the  lower  end  of  the  humerus,  although 
it  may  have  entirely  left  its  own  corresponding  articular  surface ;  thus, 
in  the  incomplete  outward  dislocation  the  sigmoid  cavity  of  the  ulna 
lies  below  and  embraces  the  external  condyle,  and  its  inner  slope  may 
still  correspond  to  the  outer  part  of  the  trochlea  or  may  have  passed 
entirely  to  its  outer  side.  In  the  complete  outward  dislocation,  on  the 
other  hand,  the  sigmoid  cavity  of  the  ulna  is  turned  toward  (pronation) 
and  embraces  the  outer  side  of  the  external  condyle  or  the  supinator 
ridge,  and  the  head  of  the  radius  lies  nearer  the  median  line  in  front 
of  the  humerus.  Much  confusion  has  arisen  from  the  use  of  the  terms 
outward  and  inward  dislocation  to  include  also  the  outward  and  back- 
ward and  the  inward  and  backward  respectively,  both  in  text-books 
and  in  the  reports  of  cases  in  the  journals.  The  terms  will  be  here 
restricted  to  those  cases  in  which  the  primary  dislocation  is  directly 


LATERAL  DISLOCATIoyS  OF  THE  ELBOW.  711 

outward  or  inward,  the  coronoid  process  remainino;  in  front  of,  and  tlie 
olecranon  behind,  the  transverse  longitudinal  (frontal)  ]>huie  of  the 
humerus.  In  some  cases  of  outward  and  backward  dislocation  the 
question  may  arise  whether  the  position  in  which  the  bones  are  found 
is  not  the  result  of  a  consecutive  displacement  following  a  primary 
outward  displacement.  I  believe  such  consecutive  displacements  to  be 
very  rare,  and  that  the  great  majority  of  backward  and  outward  dis- 
locations belong,  by  their  essential  features,  among  the  backward  ones 
with  which  I  have  above  described  them. 

In  a  dislocation  backward  and  inward  this  question  does  not  arise, 
for  a  complete  inward  dislocation  has  never  yet  been  reported  ;  l)ut  the 
confusion  is,  nevertheless,  equally  great,  for  the  epithet  "  backward 
and  inward  "  has  been  indiscriminately  applied  to  all  dis])hicements 
toward  the  inner  side,  including,  as  Trelat  pointed  out,  three  distinct 
varieties:  1st,  dislocations  of  both  bones  inward;  2d,  dislocations  of 
both  bones  backward  and  inward,  and  3d,  dislocations  backward  of  the 
ulna  alone. 

Incomplete  Lateral  Dislocations. 

Doubtless  it  must  be  attributed  to  this  confusion  in  the  use  of  terms 
that  the  frequency  of  incomplete  dislocations  to  the  outer  or  the  inner 
side  passed  unnoticed  until  1863,  when  a  German  surgeon,  Hahn,  who 
had  practised  for  more  than  forty  years  at  Stuttgart,  published  a  paper  ^ 
upon  the  subject  in  which  he  stated  that  he  had  treated  21  cases  of  this 
injury  in  thirty  years,  nearly  as  many  as  those  of  dislocation  back- 
ward observed  during  the  same  period  ;  of  these  18  were  in  children, 
3  in  adults  ;  12  of  the  former  and  2  of  the  latter  were  in  males,  and 
in  all  but  one  the  dislocation  was  inward.  The  statement,  which  was 
supported  in  many  points  by  the  observations  of  the  reviewer  of  the 
paper,  Streubel,  at  once  attracted  attention  and  has  been  confirmed  and 
accepted  by  subsequent  writers ;  the  principal  contributions  to  the  sub- 
ject have  been  made  by  Hueter,"  Nicoladoni,'^  and  8|)rengel.''  Hueter 
described  6  sj)ecimens  of  outward  dislocation  oV>tained  by  resection  and 
3  cases  observed  clinically  ;  Nicoladoni  found  4  incomplete  outward 
dislocations  in  16  dislocations  of  the  elbow  observed  in  four  and  a  half 
years ;  and  Sprengel  reported  that  the  records  of  the  Halle  clinic  for 
the  years  1873-1879  contained  32  cases,  of  which  20  were  inward  and 
12  outward.  An  important  feature  of  the  last  comnnmication  is  that 
15  of  the  32  (11  inward,  4  outward)  were  old  cases,  and  in  only  1  of 
them  could  reduction  be  obtained.  Although  it  is  not  so  stated,  it  is 
probable  that  in  many  of  them  an  error  in  diagnosis  had  been  com- 
mitted;  Hahn  says  the  injury  is  frequently  mistaken  for  fracture  of 
the  lower  end  of  the  humerus.  In  a  case  seven  months  old  reported 
by  Sprengel  the  injury  had  l)een  pronounced  by  a  well-known  London 
surgeon,  who  gave  the  ])atient  a  written  opinion,  an  intercoudyloid 
fracture  of  the  humerus,  and  he  added  that  there  was  no  trace  ol"  the 

1  Halm  :  Scliiiiidt's  .Tahrl)iiclitr,  vol.  cxix.  p.  74,  and  vol.  cxx.  \\.  HK. 
'^  HiU'tcr:   Aich.  fiir  kliii.  Cliiniiiri"',  lH(i7,  vol.  viii.  p.  l.");},  and  vol.  ix.  p.  935. 
3  Nicoladoni  :  Wieintv  nud.  Wochcnsclirift,  1876,  pp.  570,  599,  040,  and  ()70. 
*  Sprengel  :  Centralblatt  fiir  Cliinirgie,  18H0,  p.  129. 


712  DISLOCATIONS. 

dislocation  said  to  have  existed  ;  Sprengel  excised  the  joint  and  demon- 
strated the  dislocation.  On  the  other  hand,  Kronlein's  94  cases  (p. 
486)  contain  no  examples,  and  in  my  experience  they  are  relatively 
very  few. 

The  cause  is  usually  a  fall  upon  the  outstretched  hand ;  exceptional 
causes  are  falls  upon  the  inner  side  of  the  elbow  and  blows  received 
upon  the  forearm.  The  interlocking  of  the  central  ridge  of  the  sig- 
moid cavity  in  the  groove  of  the  trochlea  is  such  that  direct  lateral 
displacement  without  preliminary  separation  of  the  articular  surfaces, 
or  without  their  fracture,  is  impossible,  and  it  is  highly  probable 
that  the  dislocation  is  produced  by  abduction  of  the  completely  ex- 
tended forearm,  or  possibly  by  its  equivalent  pronation  when  partly 
flexed — that  is,  the  ulna  is  moved  downward  (in  the  prolongation  of 
the  frontal  plane  of  the  humerus)  and  outward,  turning  upon  the 
humero-radial  articulation  as  a  centre,  and  thus  the  internal  lateral 
ligament  is  ruptured.  The  joint  is  thus  opened  upon  its  inner  side, 
the  sigmoid  cavity  and  trochlea  separated  from  each  other,  and  only 
the  radius  and  capitellum  remain  in  contact  at  their  outer  borders.  If 
now  the  capitellum  slips  inward  along  the  upper  surface  of  the  radius 
an  incomplete  outward  dislocation  is  produced  ;  if,  on  the  contrary,  the 
radius  slips  inward  along  the  capitellum  an  incomplete  inward  disloca- 
tion is  the  result.  This  mechanism  can  be  reproduced  upon  the  cadaver, 
but  it  must  be  admitted  that  the  explanation  is  theoretical ;  accurate 
clinical  observations,  for  reasons  often  above  referred  to,  are  not  obtain- 
able, and  it  is  impossible  to  reproduce  all  the  factors  upon  the  cadaver. 


A.    Incomplete  Inward  Dislocations. 

Pathology.  The  autopsies  and  direct  examinations  that  have  been 
reported  and  are  available  to  show  the  new  relations  of  the  bones  are 
few  in  number.  There  are  two  autopsies  reported  by  Broca^  and 
Jolivet,^  and  the  case  above  referred  to  in  which  Sprengel  excised  the 
joint  seven  months  after  the  injury  was  received.  In  the  latter  the 
head  of  the  radius  rested  against  the  lateral  part  of  the  trochlea,  and 
the  ulna  was  displaced  so  far  inward  that  nearly  half  of  the  sigmoid 
cavity  projected  free  beyond  the  trochlea ;  upon  this  free  part,  and 
united  with  it,  lay  the  fractured  tip  of  the  epitrochlea.  There  Avas 
close  fibrous  imion  between  the  opposing  surfaces. 

Broca's  case  was  a  much  older  one ;  the  specimen  and  a  plaster  cast 
of  the  limb  are  preserved  in  the  Musee  Dupuytren.  It  differs  from 
the  usual  clinical  form  in  the  very  marked  displacement  downward 
and  backward  of  the  head  of  the  radius.  The  new  joint  permitted  full 
flexion  and  almost  complete  extension,  and  the  axis  of  the  forearm  was 
inclined  downward  and  outward  30  degrees  from  the  prolongation  of 
that  of  the  humerus.     The  distance  between  the  prominences  formed 

1  Broca  :  Bull,  de  1m  Soc.  Anatomique,  1849,  p.  272. 
^  Jolivet :  Bull,  de  la  Soc.  Anatomique,  1865,  p.  184, 


LATERAL  DISLOCATIONS  OF  THE  ELBOW.  713 

by  the  tip  of  the  olecranon  and  tlie  head  of  the  radins  was  six  centi- 
metres. There  remained  no  trace  of  the  lateral  and  annular  ligaments  ;  a 
fibrous  capsule  of  new  formation  connected  the  bones  with  one  another. 
Broca  says  there  was  no  sign  of  former  fracture,  but  Denuc6/  who  ap- 
pears to  have  examined  the  specimen,  says  the  external  condyle  appears 
to  have  been  broken  off  and  displaced  forward.  The  sigmoid  cavity 
embraces  the  epitrochlea,  and  forms  a  new  articulation  with  it ;  the 
radius  lies  below  the  inner  part  of  the  trochlea  and  projects  notably  be- 
hind it. 

Jolivet's  specimen  was  obtained  by  amputation  eighteen  months  after 
the  injury.  The  elbow  was  flexed,  the  forearm  semipronated,  and 
there  was  very  slight  mobility.  The  olecranon,  displaced  inward, 
embraced  the  epitrochlea  by  its  sigmoid  cavity  and  projected  beyond 
its  inner  side.  The  olecranon  fossa  was  empty  ;  the  anterior  and  inner 
part  of  the  head  of  the  radius  rested  upon  the  outer  articular  half  of 
the  trochlea,  the  sharp  inner  border  of  the  latter  lying  like  a  wedge 
between  the  radius  and  ulna.  The  coronoid  process  lay  in  a  new 
groove  formed  at  the  expense  of  the  epitrochlea  and  the  adjoining  side 
of  the  trochlea.  The  posterior  edge  of  the  head  of  the  radius  could 
be  felt  as  a  prominence  at  the  back  of  the  joint. 

Both  lateral  ligaments  are  necessarily  torn  ;  the  annular  ligament 
may  perhaps  resist,  though  it  must  at  least  be  put  upon  the  stretch  by 
the  interposition  of  the  inner  anterior  edge  of  the  trochlea  between 
the  head  of  the  radius  and  the  coronoid  process.  The  clinical  features 
indicate  that  the  head  of  the  radius  lies  rather  below  than  directly  in 
front  of  the  trochlea,  even  in  flexion  of  the  elbow  at  a  right  angle. 

Symptoms.  The  axis  of  the  forearm  is  parallel  with  that  of  the 
arm  and  a  little  to  its  inner  side.  The  prominence  of  the  epitrochlea 
is  lost,  that  of  the  outer  epicondyle  increased.  Flexion  and  extension 
are  quite  free,  and  painless  within  certain  limits. 

On  palpation,  the  olecranon  can  be  recognized  immediately  behind 
the  position  of  the  epitrochlea  and  extending  so  far  to  the  inner  side 
as  to  mask  this  prominence  completely  ;  the  triceps  shows  as  a  rather 
prominent  elevation  running  downward  and  inward.  The  external 
condyle  can  be  plainly  felt,  and  the  absence  of  the  head  of  the  radius 
from  its  normal  position  recognized ;  the  latter  can  sometimes  be  felt 
below  the  empty  olecranon  fossa. 

Treatment.  Reduction  in  recent  cases  appears  to  be  easy  by  traction 
in  the  extended  position  and  direct  pressure  upon  the  side  of  the  ulna. 
Theoreticalh^  outward  lateral  flexion  combined  with  moderate  traction 
and  followed  by  direct  pressure  ought  to  effect  reduction  readily  and 
without  risk  of  fracture,  especially  if  anaesthesia  is  employed. 

Sprengel's  statistics,  quoted  above,  indicate  that  reduction  is  very 
difficult  in  old  cases ;  out  of  eleven  only  one  was  reduced,  but  the 
length  of  time  that  had  elapsed  is  not  given  except  in  the  one  case  that 
was  reduced,  eight  weeks. 

Broca's  specimen  and  two  of  Sprengel's  cases  show  that  the  Joint, 

1  Denucc  :   Diet,  dc  M('d.  et  Cliir.  praticjiics.  art.  Coudc,  p.  765. 


714 


DISLOCATIONS. 


even  if  reduction  is  not  made,  may  have  a  free  range  of  motion  and 
the  h'mb  may  be  useful ;  in  his  other  cases  Sprengel's  attempts  to 
increase  the  range  of  motion  failed  more  or  less  completely. 


B.  Incomplete  Outward  Dislocations. 

This  form,  although  apparently  somewhat  less  frequent  than  the  pre- 
ceding, has  been  more  fully  studied.  Its  causes  and  mechanism  have 
been  described  above. 

Pathology.  Fig.  416  represents  a  specimen  from  an  old  case  pre- 
sented to  the  Societe  Anatomique  by  Poumet;  it  is  described  by  Mal- 
gaigne,  Denuc§,  and  Pingaud  as  one  of  the  only  two  cases  known, 
the  other,  Pinel's,  being  very  similar.  The  list  has  since  been  increased 
by  the  live  specimens  obtained  by  Hueter  by  resection,  by  Hutch- 
inson's autopsy,  and  by  Sprengel's  case  in  which  the  dislocation  be- 
came compound.  A  case  which  I  reduced  by 
Fig.  416.  arthrotomy    three   weeks    after    the    accident 

belongs,  I  think,  in  this  class,  although  the 
coronoid  process  lay  behind  the  external 
condyle ;  the  epitrochlea  lay  in  the  groove  of 
the  trochlea,  and  a  mass  of  new  bone  had 
formed  on  the  back  of  the  external  condyle. 
The  last  three  are  the  only  examples  of  the 
condition  in  the  recent  state  of  which  I  have 
knowledge,  and  the  information  furnished  by 
Sprengel's  relates  only  to  the  position  of  the 
bones. 

Sprengel's^  patient  was  a  girl  seven  years 
old ;  the  injury  was  caused  by  a  fall,  was  sup- 
posed to  be  a  fracture,  and  w^as  treated  by 
immobilization  in  a  gypsum  dressing.  Five 
weeks  later  she  came  under  Sprengel's  obser- 
vation. On  removal  of  the  dressing  a  slough 
an  inch  in  diameter  was  found  to  have  formed, 
and  through  the  opening  created  by  it  the  in- 
ternal condyle  presented.  The  head  of  the 
radius  could  be  distinctly  felt  below  the  external  condyle,  the  ulna 
was  displaced  outward  so  that  the  outer  half  of  the  sigmoid  cavity 
embraced  the  capitellum  ;  the  forearm  was  pronated  and  fixed  in  a 
position  midway  between  flexion  and  extension.  Forcible  abduction 
was  made  as  a  preliminary  to  reduction,  and  the  o])ening  of  the  slough 
was  thereby  so  enlarged  that  the  position  of  the  bones  as  described 
was  verified  by  direct  inspection.     The  child  made  a  good  recovery. 

Hutchinson's^  specimen  was  of  a  recent  case,  the  patient  having 
died  of  associated  injuries.  The  dislocation  had  been  reduced  durinij; 
life;  on  the  table  it  could  be  easily  reproduced,  and  the  bones  could 
be  dislocated   to    either  the   outer  or   the   inner  side.      The    sigmoid 


Old  incomplete  outward  dis 
location.    (Poumet.) 


'  .Sprongcl :  Loo.  cit. 

'  Hutchinson  :  Medical  Times  and  Gazette,  1866,  vol.  i.  p.  410. 


OUTWARD  DISLOCATIONS   OF  THE  ELBOW.  7l5 

notch  rested  against  the  external  condyle  and  the  head  of  the 
radius  projected  beyond  the  latter.  The  lateral  ligaments  were 
completely  torn,  and  there  were  several  rents  in  the  anterior  one ; 
the  orbicular  ligament  was  entire,  but  much  stretched.  Small  por- 
tions of  cartilage  had  been  broken  from  the  articular  surfaces  of  all 
three  bones. 

Poumet's  specimen  (Fig.  416)  is  thus  described  by  Pingaud' :  "  The 
ulna,  carried  directly  outward,  has  completely  left  the  trochlea,  which 
projects  on  the  inner  side  and  contains  in  its  groove  a  large  sesamoid 
bone  [evidently  the  broken-off  epitrochlea,  vide  infra^.  The  external 
articular  slope  of  the  sigmoid  cavity  is  in  relation  with  the  caj)itelhim, 
which  is  notably  hypertrophied,  as  is  also  the  eplcondyle,  while  the 
trochlea  and  epitrochlea  are  atrophied.  The  radius,  displaced  outward 
and  especially  forward,  is  in  indirect  relations  with  the  epicondyle  and 
the  remainder  of  the  condyle,  outside  of  which  is  a  small  sesamoid 
bone  which  completes  the  surface  of  articulation  on  this  side.  It 
results  from  these  anatomical  relations  tliat  the  forearm  is  in  slight 
flexion  with  rotation  inward ;  the  ligaments,  especially  the  lateral  ones, 
are  in  great  part  ruptured. 

Hueter's  six  specimens  all  showed  the  same  displacement,  and  the 
epitrochlea  torn  oflp  and  lodged  in  the  groove  of  the  trochlea.  The 
same  avulsion  of  the  epitrochlea  was  found  in  my  case  and  clinically 
in  sev^en  others,  Albert  and  von  Dumreicher''  each  one,  Hueter'  three, 
and  Eversham  *  two,  in  two  of  wliich  it  prevented  reduction,  and  in 
the  others  made  reduction  very  difficult.  In  two  other  cases,  also 
observed  clinically  by  Nicoladoni,  in  which  reduction  was  not  attempted 
because  of  the  length  of  time  that  had  passed  since  the  injury  was 
received,  fourteen  and  five  months  respectively,  the  epitrochlea  was 
broken  off;  in  one  it  could  not  be  found,  in  the  other  it  lay  below  and 
near  the  sharp  inner  edge  of  the  trochlea. 

Nicoladoni,  after  experimenting  upon  the  cadaver,  reached  the  opin- 
ion, which  seems  to  be  correct,  that  this  avulsion  of  the  epitrochlea  is 
effected  through  the  attached  flexor  muscles  and  not  through  the  inter- 
nal lateral  ligament  which  is  inserted  only  upon  its  base. 

His  experiments  show  that  the  internal  lateral  ligament  is  always 
ruptured,  usually  close  to  its  insertion  at  the  base  of  the  epitrochlea, 
but  sometimes  nearer  to  or  at  its  attachment  to  the  ulna.  The  rupture 
extends  backward  along  the  margin  of  the  sigmoid  cavity  to  the  tip 
of  the  olecranon,  and  in  front  through  the  anterior  ligament  to  the 
outer  side  of  the  coronoid  process.  The  external  lateral  and  the 
annular  ligaments  are  untorn.  The  clinical  cases  indicate,  however, 
that  the  annular  ligament  also  is  sometimes  ruptured. 

Symptoms.  The  elbow  is  somewhat  flexed,  the  angle  varying  in  the 
different  cases,  the  forearm  pronated.  The  axis  of  the  forearm  is 
sometimes  parallel  with  and  external  to  that  of  the  arm,  sometimes 
adducted.      The  prominence  of  the  internal  condyle  is  increased,  and 

'  Pingaud:  Loc.  cit.,  p.  526. 

^Nicoladoni:  Loc.  cit.,  p.  671. 

^Heuter:   Arch,  fiir  klin.  Chir.,  vol.  ix.  p.  935. 

■^Eversham:  Deutsche  Zeitschrift  fur  Chir.,  vol.  Ix.  p.  528. 


716 


DISLOCATIONS. 


the  skin  is  tightly  stretched  over  it.  The  transverse  diameter  of  tlie 
elbow  is  increased  by  the  projection  of  the  muscles  and  the  head  of 
the  radius  on  the  outer  side.  Flexion  and  extension  are  painful  and 
restricted.  In  the  reported  cases  no  mention  is  made  of  lateral 
mobility. 

On  palpation  the  epitrochlea,  unless  broken  off,  is  very  readily  felt ; 
if  it  is  broken  off,  the  inner  side  and  edge  of  the  trochlea  can  be 
plainly  traced,  and  the  epitrochlea  may  perhaps  be  recognized  as  a 
movable  body  below  it,  or  it  may  have  been  drawn  past  the  edge  of 
the  trochlea  into  its  groove  where  it  cannot  be  felt. 

On  the  outer  side  the  head  of  the  radius  projects  in  a  line  with  the 
anterior  or  under  surface  of  the  condyle,  according  as  the  elbow  is 
more  or  less  flexed.  The  olecranon  is  more  prominent  than  normal, 
because  it  is  lifted  out  of  its  fossa  and  lies  against  the  back  of  the 
more  prominent  external  condyle ;  it  is  distant  from  the  epitrochlea  about 
two  inches.  The  triceps  appears  as  a  prominent  cord  directed  down- 
ward and  outward  to  the  olecranon.  The  external  epicondyle  may  be 
felt  by  pressing  the  finger  firmly  in  above  the  head  of  the  radius  and 
behind  the  prominence  formed  by  the  extensor  muscles  of  the  hand. 

According  to  Pingaud,  the  forearm  is  so  pronated  that  the  posterior 
surface  of  the  ulna  looks  outward,  and  the  head  of  the  radius  lies  in 
front  of  the  capitellum  instead  of  being  displaced  outwardly.  Such 
cases  belong,  I  think,  to  the  class  of  dislocations  of  the  ulna  alone. 

Treatment.  The  first  indication  of  treatment  is  to  lift  the  central 
ridge  of  the  sigmoid  cavity  and  the  coronoid  process  out  of  the  groove 
between  the  capitellum  and  the  trochlea,  or,  in  other  words,  to  separate 
this  portion  of  the  ulna  sufficiently  from  the  under  surface  of  the 
humerus  to  allow  it  to  be  pushed  inward  past  the  projecting  outer 
border  of  the  trochlea.  This  may  be  effected  by  hyperextension,  or 
by  outward  lateral  flexion  if  the  head  of  the  radius  still  rests  against 
the  under  surface  of  the  humerus  so  as  to  form  a  fulcrum  or  centre  for 
the  movement. 

If  hyperextension  is  made,  the  movement  takes  place  about  the  tip. 
of  the  olecranon  as  a  centre,  where  it  rests  against  the  back  of  the 
humerus,  and  the  coronoid  process  is  carried  downward  away  from  the 
humerus  as  well  as  backward,  and  when  the  separation  is  sufficient 
direct  pressure  with  the  thumbs  upon  the  head  of  the  radius  will  force 
the  bones  into  place,  or  rotation  of  the  ulna  inward  (supination)  will 
carry  the  tip  of  the  coronoid  process  past  the  margin  of  the  trochlea 
into  the  groove.  Nicoladoni  suggests  that  in  the  latter  manoeuvre  an 
assistant  should  press  with  his  thumb  upon  the  back  of  the  olecranon 
to  prevent  the  production  of  a  backward  dislocation. 

Outward  lateral  flexion  should  be  aided  by  traction  upon  the  extendec? 
or  slightly  flexed  forearm,  by  which  the  articular  surfaces  will  be  sepa- 
rated as  far  as  the  untorn  ligaments  will  permit,  then  pressure  by  the 
thumb  upon  the  head  of  the  radius  will  force  the  inner  ends  of  the 
bones  back  into  line,  and  the  straightening  of  the  limb  completes  the 
reduction. 

If  the  annular  ligament  is  torn,  its  outer  portion  and  the  adjoining 
part  of  the  external  lateral  ligament  may  be  interposed  between  the 


OUTWARD  DISLOCATIONS  OF  THE  ELBOW.  717 

radius  and  the  humerus  and  oppose  tlie  return  of  the  former ;  under 
such  circumstances  the  uhia  can  still  he  reduced,  but  the  lateral  i)ress- 
ure  to  effect  this  must  be  made  upon  the  olecranon  instead  of  the 
radius,  and  then  by  pronating  and  adducting  the  forearm  the  radius  is 
drawn  past  the  obstacle  into  place.  The  suggestion  of  the  existence 
of  this  obstacle  and  of  the  means  by  which  it  may  be  avoided  rests 
entirely  upon  experiments  on  the  cadaver.  I  do  not  know  that  it  has 
ever  been  encountered  and  thus  overcome  in  practice. 

The  complication  of  avulsion  of  the  epitrochlea  and  its  lodgement 
in  the  groove  of  the  trochlea  seriously  increases  the  difficulty  of  reduc- 
tion. As  above  stated,  in  two  of  the  five  recent  cases  in  which  it  was 
recognized  reduction  failed.  The  reason  of  the  failure  is  that  the  dis- 
placement of  the  fragment  from  the  groove  by  the  returning  ulna  is 
prevented  by  the  sharply  inclined  inner  slope  of  the  trochlea  and  by 
the  pressure  of  the  overlying  muscles  and  fascia.  The  fragment  needs 
to  be  drawn  downward  as  well  as  pushed  inward.  Albert  succeeded 
by  flexing  the  forearm  at  a  right  angle,  and  then  drawing  it  forcibly 
away  from  the  humerus  in  the  direction  of  the  long  axis  of  the  latter 
by  means  of  a  cord  passed  across  its  anterior  surface  close  to  the 
elbow.  The  same  method,  when  employed  by  von  Dumreicher,  failed, 
as  did  also  forcible  outward  lateral  flexion  and  traction,  although  car- 
ried so  far  as  to  threaten  rupture  of  the  skin  on  the  inner  side  of  the 
joint. 

Possibly  the  transformation  of  the  dislocation  into  the  direct  back- 
ward form,  or  backward  and  inward,  would  remove  the  fragment  from 
the  groove  and  make  reduction  possible,  or  it  might  be  practicable  to 
draw  the  fragment  downward  out  of  the  way  by  a  sharp  hook  passed 
through  the  skin.  Other  means  failing,  the  obstacle  could  be  easily 
reached  and  removed  through  an  incision  on  the  inner  side. 

Complete  Dislocations  Outward. 

These  dislocations,  of  which  the  first  observation  was  reported  by 
Dupuytren  in  1807,  although  the  form  had  been  described  by  Petit 
nearly  one  hundred  years  before,  were  apparently  so  rare  that  Mal- 
gaigne  could  collect  only  ten  reported  cases.  Of  late,  reports  have  so 
multiplied  that,  excluding  irregular  cases,  and  those  of  which  the 
description  is  not  sufficiently  detailed,  and  those  wdiich  seem  more 
properly  to  belong  among  the  dislocations  backward  and  outward,  the 
number  of  those  available  for  study  and  generalization  is  about  twenty- 
five.^ 

1  The  bibliog;raphy,  exchuline:  doubtful  cases,  is  as  follows:  Du])uytreii,  I^croiis  oraU's, 
vol.  i.  p.  131  ;  Bonli  y.  Bull,  de  la  Soc.  Anatomique,  1837,  p.  101  ;  Nc'laton,  I'atliol.  cliinii- 
gicale.  vol.  ii.  p.  391  ;  Neilson,  Lancet,  1844,  ii.  p.  S.'iO  :  Kolicrt,  (iaz.  des   ]l('i))itaiix.  l!^!}), 
p.  180;  Sonle,  Gaz.  Medicale,  1849,  ]).  717  ;  Verncuil  and  Tri(im't,  (ia/..  Mrdicalc,  1^51  [V] 
Piogey  and  Dubrueil,  Gaz.  des  Hopitaux,  18.")1,  p.  30 ;  Detnice,  TIk'sc  de  Paris,  is.lo ;  I'lau 
bert,  idem  ;  Puecb,  Gaz.  des  Hopitaux,  18.')9,  p.  4.34  ;  Sistach,  Bull,  de  la  Soc.  deCliirurgie, 
1866,  p.  .520  ;  Varick,  New  York   Medical   Record,  1867,  vol.   ii.   p.  387 ;  Andrews,   idem 
187.5,  p.  720;  Von  Pitha,  Pitba  and  Billroth's  fbirurgie,  vol.  iv.,  abt.  2,  B,  p.  71,  4  cases 
Hatry,  Lyon  Medical,  1876,  vol.  xviii.  j).  i:';  Wylie,  in  Ilaniilton's    Fractures  and   Dislo 
cations,  p.  698;  Bertiii,  Union  Med..  I,s76.  )..  (=0!);  Osborne,  New  York    Hospital  (ia/.ette 
1879,  p.  613;  Mason,  New  York    Medical    Record,  IHKO,  vol.   xvii.  J).  397,  2  cases  ;  Towne 
idem,  p.  52.5  ;  Ekwurzcl,  Pliiladeli)liia  Medical  and  Surgical  Reporter,  1881,  vol.  xlv.  p< 


718  DtSLOGATIOm. 

In  most  of  the  cases  the  mechanism  of  production  cannot  be  deter- 
mined, but  the  histories  of  a  few  are  sufficiently  complete  to  show  that 
the  cause  may  be  a  fall  upon  the  outstretched  palm  or  upon  the  elbow, 
or  a  blow  received  upon  the  inner  side  of  the  forearm.  Hatry's  case 
is  a  clear  example  of  the  first,  the  patient  stumbled  and  fell  forward 
upon  his  hand  ;  von  Pitha's  patient,  who  fell  while  her  hands  were  in 
her  muff,  is  an  example  of  the  second  ;  and  Mears's  patient,  who  was 
struck  upon  tlie  inner  and  upper  part  of  the  forearm  by  a  revolving 
piece  of  wood  while  the  elbow  was  partly  flexed  in  an  effort  to  draw^ 
down  some  object  from  above  his  head,  is  an  example  of  the  third.  The 
mechanism  in  a  fall  upon  the  hand  is  doubtless  the  same  as  that  in 
incomplete  dislocation  outward  produced  in  the  same  manner — that  is, 
outward  lateral  flexion  is  produced  ;  the  internal  lateral  ligament  is 
ruptured,  and  then  the  bones  are  displaced  laterally  past  one  another 
by  the  continued  action  of  the  weight  of  the  body.  In  one  of  von 
Pitha's  cases  this  lateral  flexion  was  observed  by  the  mother  of  the 
patient,  a  boy,  six  years  old,  who  saw  the  elbow  bend  as  he  fell  from 
a  tree  upon  his  outstretched  hand. 

Pathology.  The  only  recorded  autopsies  are  those  of  Bouley  and 
Heinlein  ;  in  the  former,  a  compound  dislocation  with  fracture  of  the 
external  condyle  produced  by  a  fall  upon  the  elbow  from  a  height  of 
twenty-eight  feet,  amputation  was  refused,  and  the  patient  died  on  the 
twenty-fifth  day.  The  lateral  ligaments  of  the  elbow  were  entirely 
ruptured ;  both  bones  of  the  forearm  were  placed  externally  to  the 
lower  extremity  of  the  humerus,  and  the  ulnar  nerve  was  lacerated  at 
the  level  of  the  trochlea.  In  the  latter  both  lateral  and  the  anterior 
ligaments  were  torn,  the  radial  nerve  bruised  ;  a  fragment  was  broken 
from  the  head  of  the  radius,  and  the  coronoid  process  was  broken. 
The  radius  and  ulna  were  also  broken  near  the  middle. 

Disregarding  one  or  two  exceptional  forms,  the  cases  may  be  grouped 
in  three  classes  according  to  the  character  of  the  displacement,  but  in 
some  the  account  is  not  sufficiently  complete  to  determine  to  \vhich 
class  the  case  should  belong.  In  one,  apparently  the  least  frequent, 
the  displacement  is  directly  outward  and  a  little  upward,  so  that  the 
inner  edge  of  the  sigmoid  cavity  rests  against  the  outer  surface  of  the 
external  condyle,  the  elbow  being  partly  flexed,  with  the  olecranon 
behind  and  the  coronoid  process  in  front  of  the  epicondyle.  The 
radius  preserves  its  relations  with  the  ulna  and  is  situated  still  further 
to  the  outer  side,  or  is  carried  to  a  somewhat  higher  level  by  pronation 
of  the  forearm.  This  involves  complete  rupture  of  the  lateral  and  an- 
terior ligaments.  In  Neilson's  case  it  was  thought  the  external  condyle 
was  broken  ;  the  olecranon  was  three  inches  above  its  usual  position. 

In  the  second  class  the  forearm  is  pronated  as  well  as  flexed,  and 
this  pronation  is  effected  by  rotation  about  the  long  axis  of  the  ulna, 
so  that  the  head  of  the  radius  lies  above,  or  even  further  inward  than, 

38;  Mears,  Philadelphia  Medical  Times,  1S80-1,  vol.  xi.  p.  89;  Johnson,  Transactions  of 
the  Missouri  State  Medical  Association,  1880,  p.  33 :  Battiscombe,  Lancet,  1886,  ii.  p. 
397;  Heinlein,  Centbl.  fiir  Chir.,  February  1,1890;  Stimson,  here  given;  Winslow, 
Annals  of  Surgery,  May,  1900,  p.  595.  I  have  not  been  able  to  verify  the  reference 
for  Dupuytren's  and  Verneuil's  cases.  The  Gazette  Medicale  for  18ol  does  not  con- 
tain the  latter;  in  the  Gazette  des  Hopitaux,  1851,  pp.  93  and  201,  is  an  article  by 
Verneuil  and  Triquet  which  contains  a  case  of  incomplete  outward  dislocation. 


OUTWARJ)  DiSLOCATlO}^^S   OF  THE  ELBOW.  719 

the  ulua.  The  great,  sigmoid  cavity  embraces  the  outer  surface  of  the 
external  condyle,  the  tip  of  the  olecranon  lying  behind  the  condyle 
and  that  of  the  coronoid  process  in  front  of  it.  The  anterior  surface 
of  the  nina  looks  inward.  The  head  of  the  radius  lies  above  its  nor- 
mal position,  in  front  of  the  humerus,  and  possibly  still  in  contact  with 
the  upper  part  of  the  articular  surface  of  the  capitellum.  Study  of 
the  skeleton  indicates  that  this  form  can  be  easily  produced  from  an 
incomplete  outward  dislocation  by  pronation  of  the  limb  ;  it  is,  I  think, 
the  most  common  of  the  three  classes,  and  it  seems  possible  that  the 
external  lateral  ligament  may  be  preserved  untorn.  Denuee  has  given 
it  the  name  of  sub-epicondi/lar,  in  distinction  from  the  following,  tiiird 
class,  which  he  terms  supra-epicondylor.  He  thinks  the  distinction  is 
an  important  one  and  that  the  difference  depends  upon  the  rupture  or 
the  integrity  of  the  attachment  of  the  muscles  upon  the  epicondyle. 

In  the  third  class  the  ulna  and  radius,  pronated  and  flexed,  are  car- 
ried higher  up  along  the  outer  border  of  the  humerus,  two  inches  in 
Osborne's  case.  The  sigmoid  cavity  may  embrace  the  supinator  ridge, 
and  tile  radius  still  lie  in  front  of  the  humerus,  or  both  bones  may  be 
displaced  also  backward  so  that  the  coronoid  process  and  the  articular 
surface  of  the  radius  are  posterior  to  the  ridge. 

It  is  noteworthy  that  in  none  of  the  cases  is  fracture  of  the  epi- 
trochlea  mentioned  ;  in  one  or  two  it  is  said  that  the  epitrochlear 
muscles  were  torn  away  at  their  insertion. 

Two  cases,  in  which  an  additional  consecutive  displacement  had  fol- 
lowed by  which  both  bones  were  brought  around  in  front  of  the 
humerus  and  pronated  so  far  that  their  posterior  surfaces  were  directed 
forward,  were  reported  by  Cloquet^  and  Maisonneuve.^  The  latter's 
patient  was  a  woman  who  had  fallen  out  of  bed  upon  her  elbow,  and 
who  was  so  thin  that  the  position  of  the  bones  could  be  accurately 
determined  ;  the  lower  end  of  the  humerus  projected  prominently 
behind  and  was  there  covered  only  by  the  skin,  while  the  triceps 
ran  forward  and  outward  over  the  epicondyle.  The  ulna  was  com- 
pletely turned  around  so  that  its  posterior  surface  looked  forward  and 
the  sigmoid  cavity  lay  against  the  front  of  the  trochlea.  The  head 
of  the  radius  could  not  be  felt.  The  limb  was  slightly  flexed  and 
greatly  pronated.  Reduction  was  effected  by  moving  the  olecranon 
out\vard  and  backward  around  the  external  condyle  to  tlie  back  of  the 
humerus,  and  then  reducing  in  the  usual  manner  the  backward  disloca- 
tion thus  produced. 

Symptoms.  Of  the  first  variety,  dislocation  directly  outward,  with- 
out rotation  of  the  forearm  (Fig.  417),  Puech's  case  may  be  taken  as 
a  type.  The  patient  was  a  man  forty-one  years  old,  and  tiie  injury 
was  caused  by  a  fall  from  a  height  of  about  two  feet,  the  elbow  striking 
against  some  stones.  The  forearm  was  extended  and  supinated  ;  it 
could  be  passively  flexed  nearly  to  a  right  angle,  but  could  not  be  pro- 
nated; its  axis  lay  entirely  to  the  outside  of  the  humerus,  and  the 
transverse  diameter  of  the  ell)()W  was  nearly  doubled.  Ti'acing  the 
hones  with   the    finger   Ix'hind,  (Voiii   tlic  cpitrocldca    outward,  the  sur- 

1  Cloquet:  Quoted  by  Mnle:'iisne,  loc.  cit.,  p.  616. 
^  Maisonneuve  :  Gaz.  dcs  Iioi^itaux,  1867,  p.  145. 


720 


DISLOGATWm. 


p;eoii  reco2;nized  all  the  points  of  the  lower  end  of  the  humerus,  then 
the  olecranon  well  above  and  to  the  outer  side  of  the  condyle,  and  then 


Fig  417. 


Fig.  418. 


Cuiuplete  outward  dislocation. 
(Denuci^:.) 


Complete  outward  dislocation  of  the  elbow.    Supra- 
epicondylar.    (Stimson.) 

the  head  of  the  radius  lower  than  the 
olecranon  but  still  above  the  lower 
line  of  the  humerus.  In  other  similar 
cases  extreme  mobility  of  the  joint  is 
mentioned;  as  if  the  two  segments  of 
the  limb  were  very  loosely  attached  to 
each  other. 

In  the  second  variety,  "sub-epi- 
Gondylar,^^  the  axis  of  the  forearm 
appears  generally  to  be  inclined  downward  and  inward  (adduction) ; 
flexion  at,  or  even  within  (Pitha),  a  right  angle  is  common  ;  semi-pro- 
natiou  or  full  pronation.  The  transverse  diameter  of  the  elbow  is 
increased,  but  not  so  much  as  in  the  preceding  variety.  The  supinator 
and  radial  extensor  muscles  form  a  well-defined  prominence  above  and 
in  front  of  the  joint ;  the  tendon  of  the  triceps  shows  as  a  prominence 
directed  downward  and  outward,  and  the  tendon  of  the  biceps  can 
sometimes  be  felt  running  in  the  same  direction  in  front. 

The  outlines  of  the  lower  end  of  the  humerus  can  be  distinctly 
traced  from  the  epitrochlea  outward  to  the  capitellum  ;  the  external 
epicondyle  is  masked  by  the  ulna,  but  sometimes  can  be  felt  by  press- 
ing the  finger  deeply  in  above  the  latter.  The  cup-shaped  surfoce  of 
the  head  of  the  radius  can  be  felt  unless  it  has  been  carried  so  far 
inward  by  the  pronation  of  the  limb  that  it  rests  against  the  front  of 
the  humerus. 

In  the  third  variety,  "  supra-epicondylar  "  (Fig.  418),  the  forearm 
is  flexed  at,  or  nearly  at,  a  right  angle  and  pronated  ;  the  transverse 
diameter  at  the  lower  part  of  the  arm  is  increased.  The  greater  the 
disi)lacement  upward,  the  greater  is  the  passive  mobility  of  the  limb 
in  the  plane  of  flexion  and  extension.  The  lower  end  of  the  humerus 
is  accessible  to  the  touch  even  more  completely  than  in  the  two  preced- 


FORWARD   DISLOCATIONS  OF   THE  ELBOW.  721 

ing  varieties,  for  it  projects  completely  below,  and  even  its  external 
condyle  can  be  traced.  The  deformity  on  the  outer  side  varies  with 
the  extent  and  character  of  the  final  displacement,  for  the  bones  of  the 
forearm  are  sometimes  carried  backward,  crossing  the  humerus,  or,  as 
in  Maisonneuve's  and  Cloquet's  cases,  carried  forward  to  the  front  of 
the  humerus. 

It  is  noteworthy  that  in  three  of  the  four  cases  in  which  reduction 
was  not  made  the  patients  had  good  control  of  the  limb  and  a  free 
range  of  motion  was  established.  Wylie's  patient  thought  his  arm 
was  as  serviceable  as  ever.  Robert's  patient  was  seventy  years  old 
and  his  injury  dated  from  infancy  ;  he  had  an  extensive  range  of 
flexion  and  extension.  In  Denuce's  case  (Fig.  417)  the  olecranon 
projected  nearly  an  inch  behind  the  humerus,  the  arm  could  be  fully 
extended  and  flexed  nearly  to  a  right  angle.  In  Nekton's  case  there 
was  flexion  nearly  at  a  right  angle. 

It  is  also  noteworthy  that  in  no  case  were  there  symptoms  of  inter- 
ference with  the  circulation,  and  in  only  one  case  (Mears)  were  there 
symptoms  of  injury  to  the  nerves.  In  his  there  were  pain  in  the  fingers 
and  numbness  in  the  distribution  of  the  median  nerve. 

Treatment.  Reduction  has  been  eff'ected  without  difficulty  in  all  the 
recent  cases,  except  Winslow's,  by  extension  and  direct  manipulation  of 
the  upper  ends  of  the  radius  and  ulna.  The  laceration  of  the  ligaments 
and  muscles  is  so  great  that  the  bones  are  freely  movable,  and  special 
manoeuvres  intended  to  relax  opposing  bands  are  seldom  necessary.  Ex- 
ceptions to  this  may  be  found  sometimes  in  the  first  and  second  varieties  ; 
in  the  first  the  head  of  the  radius  may  pass  through  and  be  caught,  as 
apparently  happened  in  Puech's  case,  between  two  muscular  bundles, 
which  may  then  need  to  be  relaxed  by  flexing  and  abducting  the  fore- 
arm ;  in  the  second,  which  appears  sometimes,  as  has  been  said,  to 
differ  from  the  incomplete  outward  dislocations  only  in  the  addition  of 
pronation  of  the  forearm,  the  external  lateral  ligament  remaining 
nntorn,  the  first  movement  must  be  to  supinate  the  limb  and  thus  turn 
the  sigmoid  cavity  under  the  capitellum  and  bring  the  head  of  the 
radius  to  the  outer  side  ;  the  dislocation  is  then  an  incomplete  outward 
one,  and  is  reduced  accordingly.  In  a  case  in  which  previous  attoni])ts 
by  traction  in  extension  under  anaesthesia  by  other  surgeons  had  fiiilcd 
I  reduced  easily  by  flexing  the  elbow  at  a  right  angle  and  })ressing 
the  head  of  the  radius  downward  and  around  the  lower  outer  edge  of 
the  condyle. 

DISLOCATIONS    OF    THE    FOREARM    FORWARD. 

Although  mentioned  by  Hippocrates  and  characterized  by  him  as  the 
most  painfid  of  all  and  fatal  in  a  few  days,  and  admitted  by  all  sub- 
sequent writers,  the  first  recorded  case  (and  that  a  (piestionable  one)  of 
this  dislocation  was  published  only  a  hundred  years  ago,  and  the  nmn- 
ber  has  not  yet  reached  twenty-five,  even  including  seven  cases  in 
which  the  olecranon  was  broken  off' and  remained  in  place.' 

Of  the  14  cases  in  which  the  age  is  mentioned,  1  was  six  years  old, 
3  were  eight,  2  fourteen,  2  fifteen,  and  1  each  eighteen,  twenty,  thirty- 

'  The  l)il)liogniphy  is  as  follows:  Evcrs,  Monin,  (;ii\d(.  Wit  l  linjior,  (luotcd  liy  Stri-ulicl 
in  Prager  Vierteljahrschnft,  1850,  ii,  p.  37,  and  l)y  MalKaigiio,  ioc.  cit.,  p.  01^(5;  Ciuorr, 


722  DISLOCATIONS. 

four,  thirty-eight,  and  forty  years  old,  1  was  an  "adult,"  and  1 
"  middle  aged."  The  cause  in  the  greater  number  of  cases  appears  to 
have  beenli  fall  upon  the  flexed  elbow ;  in  one  (Pryor)  it  was  a  blow 
by  the  handle  of  a  crane  upon  the  back  of  the  elbow ;  in  two  certainly 
(Date,  Ray),  and  probably  in  others,  it  was  a  fall  upon  the  palm  of  the 
hand  ;  in  Fulton's  it  was  traction  on  the  extended  arm,  without  frac- 
ture of  the  olecranon ;  in  one  (Caussin)  the  patient's  hand  was  caught 
between  two  cogwheels  and  both  bones  of  the  forearm  were  broken  at 
the  middle    as    well  as  dislocated ;    and   in  one  (Morel-Lavallee)  the 

Fig.  419. 


Fracture  of  olecranon  ;  dislocation  forward  of  radius  and  remainder  of  ulna. 

patient  fell  from  a  wagon  and  was  run  over,  the  wheel  passing  across 
the  elbow  and  breaking  the  olecranon  and  coronoid  process. 

quoted  by  Pingaud  in  Diet,  Encyclopedique,  1st  ser.,  vol.  xxi.  p.  708;  Chapel,  quoted  by 
Malgaigne,  loc.  cit.,  p.  617,  as  a  dislocation  outward  ;  Colson,  Leva,  quoted  by  Debruyn 
in  Annales  de  la  Chirurgie  Fraugaise  et  Etrangere,  1843,  vol.  ix.  pp.  44  and  45,  and  by 
Streubel;  Eichet,  Archives  generales,  1839,  vol.  vi.  p.  472;  Prior,  Lancet,  1844.  ii.  p.  366; 
Ancelon,  L'Union  Medicale,  1859,  vol.  iii.  p.  394;  Canton,  Dublin  Medical  Journal,  1860, 
ii.  p.  24  ;  Secrestan,  Gazette  des  Hopitaux,  1860,  p.  598 ;  Caussin,  L'Union  Medicale,  1861, 
vol.  xi.  p.  475,  and  Bulletins  de  la  Societe  de  Chirurgie,  1861,  vol.  ii.  p.  451  ;  Eichet,  Bull, 
de  la  Soc.  de  Chirurgie,  1859,  vol.  ix.  p.  110;  Morel-Lavallee,  idem,  p.  107;  Greenaway, 
quoted  by  Hutchinson,  Medical  Times  and  Gazette,  1866,  i.  p.  409  ;  Langmore,  Lancet, 
abstract  in  New  York  Medical  Eecord,  1867,  vol.  ii.  p.  10;  Eigand,  Bulletins  de  la  Societe 
Anatoniique,  1870,  p.  15;  Date,  Lancet,  1872.  ii.  p.  .597;  Mons,  Deutsche  Mil.  Zeitschrift, 
1877,  p.  401 ;  quoted  by  Poinsot,  loc.  cit.,  p.  951 ;  Kronlein,  Deutsche  Chirurgie,  Lief.  26, 
p.  30  ;  Stimson,  see  Plate  XIII.  ;  Eav,  quoted  by  Piatt,  Fractures  and  Dislocations  of 
Upper  Extremity,  1899,  p.  200;  Fulton,  Med.  Eecord,  1S97,  vol.  Iii.  p.  738  ;  Staunton,  Brit. 
Med.  Journ.,  1905,  Dec.  9,  p.  1520;  Lambert,  Annals  of  Surg.,  1911,  vol.  liii,  p.  866; 
Winslow:  Surg.,  Gyn.  and  Obst.,  May,  1913,  p.  570.  References  have  also  been  made 
to  a  case  by  Ferguson,  Surgery,  3d  ed.,  p.  241,  one  by  Roser,  Chirurg.  Anat.,  1844,  p. 
477,  and  one  by  Flaubert. 


FORWARD  DISLOCATIONS  OF   THE  ELBOW.  723 

In  eight  of  the  cases  the  olecranon  was  broken,  and  in  these  the 
mechanism  of  the  dislocation  is  easily  understood,  for,  the  resistance  of 
the  olecranon  beino;  removed,  the  two  Ijones  can  be  easil}'  displac^ed 
forward  and  upward  along  the  front  of  the  humerus  by  a  force  acting 
upon  the  back  of  the  forearm.  Such  cases,  I  think,  shcndd  hardly  be 
put  in  this  class  ;  the  condition  is  secondary  to,  and  made  possible  by, 
the  fracture  of  the  olecranon.  A  personal  case  of  this  kind  is  shown 
in  Fig.  419.  I  have  recently  (1899)  seen  another.  In  the  case  of  a 
fall  or  of  a  blow  upon  the  flexed  elbow  the  direction  of  the  force  is 
probably  inclined  somewhat  away  from  the  axis  of  the  forearm  and  is 
more  nearly  jiurallel  with  the  posterior  portion  of  the  articular  surface 
of  the  olecranon,  and  it  must  be  great  enough  to  rupture  the  lateral 
ligaments  without  the  aid  of  leverage.  All  attempts  to  reproduce  the 
dislocation  ujion  the  cadaver  by  this  mechanism,  forced  flexion  and 
direct  impulsion,  have  failed,  except  after  preliminary  division  of  the 
lateral  ligaments. 

In  the  case  of  a  fall  upon  the  hand  there  is  clinical  evidence  to  show 
that  this  form  is  closely  allied  to  the  lateral  dislocations,  and  that  it  is 
produced  by  lateral  outward  flexion  supplemented  by  sufficient  torsion 
(supination)  of  the  limb  to  bring  the  olecranon  forward  under  the 
trochlea;  in  several  cases  the  displacement  was  outward  as  well  as  for- 
ward ;  in  Chapel's,  so  far  outward  that  the  case  has  been  classed  with 
the  lateral  dislocations. 

Pathology.  One  autopsy  (Richet),  three  amputations  (Canton,  Morel- 
Lavallee,  Rigaud),  two  compound  fractures  of  the  olecranon  without 
amputation  (Richet,  Guerre),  one  compound  dislocation  without  frac- 
ture (Prior),  and  experiments  upon  the  cadaver  show  how  great  the 
laceration  sometimes  is.  In  Prior's  case,  in  which  the  patient  was 
struck  upon  the  "under  side  of  the  left  arm  at  the  elbow-joint"  by 
the  rapidly-revolving  handle  of  a  crane,  there  was  a  large  wound  at  the 
point  where  the  blow  was  received,  "occasioning  a  general  disconnec- 
tion of  its  parts,  muscular  and  otherwise,  excepting  immediately  in 
front."  The  radius  and  ulna  were  driven  upward  and  forward  on  the 
humerus ;  the  condyles  of  the  latter  and  its  shaft  for  two  and  a  half 
or  three  inches  projected  through  the  wound  nearly  at  right  angles 
with  the  forearm,  as  completely  stripped  as  if  cleaned  with  a  knife. 
There  was  no  fracture.  Reduction  was  made  ;  the  patient  recovered 
after  much  suppuration  in  and  around  the  joint,  and  the  final  result 
was  good,  "the  limb  gaining  in  freedom  and  power." 

In  Canton's  case,  the  patient,  a  man  forty  years  old,  was  thrown 
from  a  wagon  ;  apparently  he  struck  upon  the  extended  hand,  but  the 
forearm  was  immediately  flexed  and  twisted  under  his  chest.  The 
forearm  was  flexed,  the  hand  supinated,  the  swelling  very  great,  and 
the  skin  tense  and  threatening  to  slough  over  the  internal  condyle.  The 
antero-posterior  and  lateral  diameters  of  the  joint  were  increased,  and 
the  head  of  the  radius  could  be  indistinctly  felt  externally  and  ante- 
riorly. The  diagnosis  was  not  made,  and  "attempts  to  correct  the 
maladjustment"  failed;  after  a  delay  of  forty-eight  hours,  during 
which  the  swelling  increased  and  sloughing  was  established,  am]iuta- 
tion  well  above  the  condvk^s  was  resorted  to. 


724 


DISLOCATIONS. 


Fig.  420. 


Examination  of  the  limb  showed  (Fig.  420)  that  the  upper  surface 
of  the  olecranon  rested  against  the  front  of  the  capitellum ;  the  annular 
and  interosseous  ligaments  were  whole,  the  anterior  ligament  was  rup- 
tured except  in  its  centre,  the  posterior 
and  both  lateral  ligaments  ruptured.  The 
triceps  was  completely  detached  from  the 
olecranon.  The  two  radial  extensor  muscles 
and  all  the  muscles  arising  from  the  epicon- 
dyle  except  the  supinator  brevis  and  the 
anconseus  were  detached,  as  was  also  the 
epitrochlear  head  of  the  flexor  carpi  ulnaris. 
The  ulnar  nerve  was  torn  behind  the  con- 
dyle. The  other  large  nerves  and  the  main 
vessels  were  uninjured. 

Richet's  first  patient  was  eighteen  years 
old  and  had  fallen  from  a  height  of  forty- 
five  feet.  The  forearm  was  slightly  flexed 
and  in  supination,  and  was  immovable ;  it 
was  shortened  an  inch,  measuring  from  the  epicondyles  to  the  lower 
ends  of  the  radius  and  ulna.  The  olecranon  was  in  place  and  movable  ; 
two  inches  below  it  was  a  large  wound  through  which  the  lower  end 
of  this  fragment  projected.     The  head  of  the  radius  and  the  broken 

Fig.  421. 


Forward  dislocation  of  the  elbow; 
Canton's  case. 


Forward  dislocation.      (Winslow.) 

end  of  the  ulna  were  recognizable  in  the  fold  of  the  elbow  a  finger- 
breadtii  above  the  condyles.  Reduction  was  easy  by  traction,  but  re- 
currence at  once  followed.  The  patient  died  three  hours  later.  The 
autopsy  showed  the  annular  ligament  to  be  intact. 

In  Lambert's  case,  in  which  reduction  was  made  by  arthrotomy  five 
weeks  after  the  accident,  the  only  details  given  are  that  the  articular 
ligament  was  unruptured,  the  triceps  only  partly  detached  from  the 
olecranon,  and  the  epitrochlea  was  broken  olf  and  attached  to  the  coro- 
noid  ;  but  the  boy  had  dislocated  the  same  joint  twice  during  the  pre- 
ceding ten  weeks  by  falling  during  epileptic  seizures.  There  was  per- 
sistent paralysis  in  the  ulnar  distribution. 


FORWARD  DISLOCATIONS  OF   THE  ELBOW.  725 

In  addition  to  these  two  varieties,  dislocation  with  and  without  frac- 
ture of  the  olecranon,  the  difference  between  which  is  so  important, 
there  is  another,  based  upon  clinical  and  experimental  evidence,  to 
which  the  name  incomplete  is  given  ;  in  it  the  upper  end  of  the  olecra- 
non rests  against  the  under  and  anterior  surface  of  the  humerus  instead 
of  passing  upward  in  front  of  it.  So  far  as  can  be  inferred  from  the 
reported  cases  it  is  the  most  common  form.  The  use  of  the  terms  first 
and  second  degree,  to  distinguish  between  the  two  forms,  is,  I  think, 
to  be  preferred  to  that  of  incomplete  and  complete. 

In  Chapel's  case  the  additional  outward  dislocation,  which  is  noted 
in  several  of  the  others,  was  so  great  that  Malgaigne  classes  it  with  the 
outward  dislocations.  The  patient  was  a  boy  fourteen  years  old.  The 
radius  formed  a  marked  prominence  under  the  skin  on  the  outer  side ; 
on  its  inner  side  could  be  felt  the  olecranon  and  its  sigmoid  cavity. 
The  two  bones  overrode  the  humerus  in  front  about  two  centimetres  ; 
the  epicondyle  lay  behind  the  ulna.  Mons's  case  seems  to  me  to  be  of 
the  same  kind.  It  is  quoted  by  Poinsot  as  a  unique  example  of  diver- 
gent dislocation,  ulna  forward  and  radius  outward.  The  description 
IS  limited  to  this  statement  and  does  not  definitely  exclude  the  possi- 
bility that  the  ulna  may  have  been  displaced  outward  as  well  as  forward. 

Fracture  of  the  epitrochlea  has  been  observed  in  one  case  (Date's),  a 
boy  fourteen  years  old,  and  this  is  the  one  in  which  the  evidence  that 
the  dislocation  was  produced  by  external  lateral  flexion  in  a  fall  upon 
the  hand  is  most  complete.  The  head  of  the  radius  was  prominent 
outside  of  and  below  the  outer  condyle  ;  above  it  was  a  deep  depression 
in  which  the  condyle  could  be  obscurely  felt ;  the  olecranon  was  below 
its  usual  position,  resting  with  its  extreme  end  against  the  trochlea 
(first  degree,  or  incomplete).  The  limb  was  semi-flexed.  Reduction 
was  easy  under  chloroform ;  the  radius  first,  and  then  the  ulna,  going 
back  into  place  with  a  distinct  snap.  If  this  account  of  the  positions 
of  the  two  bones  is  accurate  the  annular  ligament  was  probably  torn. 

Symptoms.  In  five  of  the  cases  uncomplicated  by  fracture  it  is  stated 
that  the  forearm  was  lengthened,  more  than  an  inch  in  one  of  them, 
and  with  this  coincided  a  position  of  the  limb  which  is  mentioned  in 
several  others,  namely,  slight  or  partial  flexion,  which  could  generally 
be  changed  somewhat  in  either  direction.  In  one  in  which  the  range 
of  motion  is  specified  (Langmore),  the  limb  was  held  at  an  angle  of  130 
degrees,  could  be  flexed  to  a  right  angle  and  extended  to  160  degrees; 
in  another  (Colson),  hyperextension  could  be  made  without  causing  pain, 
and  during  the  movement  the  olecranon  passed  forward  between  the 
biceps  and  pronator  teres. 

In  correspondence  with  this  lengthening  there  is  flattening  of  each 
side  and  of  the  back  of  the  elbow,  unless  the  swelling  is  sufficient  to 
mask  it,  with  prominence  of  the  inner  and  sometimes  of  the  outer  con- 
dyle, and  the  formation  of  a  transverse  sulcus  appreciable  by  the  touch 
behind  between  the  humerus  and  the  olecranon.  In  one  case  the  fore- 
arm was  also  abducted.  In  Canton's  case  the  forearm  was  flexed 
beyond  aright  angle;  the  olecranon  rested  against  the  capitellum,  and 
the  triceps  was  torn  completely  from  it.  It  seems  probable  that  detach- 
ment or  rupture  of  the  triceps  is  a  necessary  condition  of  the  passage 
of  the  olecranon  to  any  distance  along  the  front  of  the  humerus,  and 
50 


726  DISLOCATIONS. 

that  the  existence  or  absence  of  the  detachment  may  constitute  the 
essential  difference  between  the  complete  and  incomplete  forms,  or  the 
first  and  second  degrees.  The  clinical  features  which  differentiate  the 
two  forms  are  that  in  the  lesser  form  the  olecranon  is  prominent  below 
the  humerus  when  the  elbow  is  flexed,  and  the  forearm  is  lengthened 
when  it  is  extended  or  but  slightly  flexed.  In  the  second,  "  complete  " 
form,  the  forearm  is  more  or  less  shortened  when  extended,  but  is 
lengthened  when  flexed  at  or  near  a  right  angle,  and  its  antero-poste- 
rior  diameter  is  increased  because  of  the  projection  of  the  coronoid 
process  in  the  fold  of  the  elbow.  The  biceps  tendon  can  be  recognized 
on  the  outer  side  of  the  latter,  and  beyond  it  the  head  of  the  radius. 
Posteriorly,  in  both  forms,  the  olecranon  fossa  is  empty  ;  the  direction 
of  the  ulna  also  plainly  indicates  the  change  in  the  position  of  its 
upper  end  unless  the  swelling  is  great. 

Course  and  Prognosis.  In  only  one  case  (Canton)  did  the  dislocation 
remain  unreduced,  and,  as  in  this  the  diagnosis  was  not  made  because 
of  the  swelling,  there  is  reason  to  suppose  that  a  suitable  attempt 
to  reduce  would  have  been  as  successful  as  it  proved  in  the  others. 
It  was  also  the  only  case,  of  those  uncomplicated  by  a  compound  frac- 
ture of  the  olecranon,  that  did  badly  and  in  which  amputation  was 
thought  to  be  necessary.  The  history  of  the  case,  moreover,  suggests 
that  the  decision  was  reached  rather  hastily  and  on  grounds  that  might 
be  deemed  insufficient. 

Of  the  7  compound  dislocations,  of  which  6  were  complicated  by 
fracture  of  the  olecranon,  3  recovered,  2  underwent  amputation  after 
the  joint  had  suppurated,  1  died  three  hours  after  the  accident,  which 
was  a  fall  from  a  height  of  forty-eight  feet,  and  in  1  (Krdnlein)  the 
result  is  unknown.  Of  the  3  recoveries,  the  joint  suppurated  in  2 
(Prior,  Richet's  second),  the  process  ending  in  anchylosis  in  one  of  them  ; 
in  the  remaining  1  the  patient  recovered  apparently  without  suppura- 
tion, the  fracture  of  the  olecranon  united  by  a  fibrous  band  one  centi- 
metre long,  and  two  and  a  half  months  after  the  accident  the  hand 
could  be  brought  to  the  mouth  and  the  elbow  extended  to  an  angle  of 
150  degrees.  Whether  antiseptic  methods  will  improve  this  poor 
record  remains  to  be  seen. 

Treatment.  In  all  the  cases  in  which  the  olecranon  rests  against  the 
lower  part  of  the  end  of  the  humerus,  the  so-called  incomplete  dislo- 
cations, reduction  has  been  easily  effected  by  pressing  or  pulling  the 
upper  end  of  the  forearm  downward  and  backward,  or  by  flexing  the 
limb  against  the  knee  or  the  arm  of  an  assistant  placed  in  the  fold  of 
the  elbow.  In  Greenaway's  case  the  bones  slipped  into  place  almost 
spontaneously  when  the  elbow  was  flexed. 

In  the  cases  in  which  the  bones  are  displaced  further  upward  it  is 
desirable  to  flex  the  limb  within  a  right  angle  and  then  to  pull  the 
upper  ends  of  the  bones  back  into  place  by  a  strap  passed  around  the 
front  of  the  forearm  close  to  the  elbow. 

Dislocations  complicated  by  compound  fracture  of  the  olecranon  must 
be  treated  in  accordance  with  the  genernl  principles  of  treatment  of 
compound  articular  fractures,  of  which  they  are  a  severe  form,  severe 
because  of  the  greater  extent  of  the  laceration  of  the  soft  parts.  In 
my  own  case,  simple  fracture  of  the  olecranon,  seen  about  two  months 
after  the  accident,  I  made  reduction  by  an  incision  along  the  ulna 
which  exposed  the  joint  and  the  fracture. 


DIVERGENT  DISLOCATIONS  OF   THE  ELBOW.  727 

DIVERGENT  DISLOCATIONS  OF  THE   RADIUS  AND  ULNA. 

The  characteristic  feature  of  this  form  is  that  the  radius  and  ulna 
do  not  accompany  each  other,  but  are  displaced  in  divergent  directions. 
Two  varieties  have  been  observed  :  the  antero-posterior,  in  which  the 
ulna  passes  up  behind  the  humerus,  and  the  radius  passes  up  in  front 
and  of  which  there  are  fifteen  recorded  cases ;  ^  and  the  transverse,  of 
which  there  are  two  cases,  in  which  the  divergence  was  mainly  lateral, 
the  olecranon  passing  to  the  inner  side  behind  the  epitrochlea,  and  the 
radius  to  the  outer  side.^  Several  authors  make  an  additional  variety, 
ulna  backward,  radius  outward,  on  the  basis  of  the  case  of  Samuel 
White  quoted  by  Cooper,^  which  seems  to  me  to  be  a  dislocation  of 
both  bones  backward  and  outward  ;  and  Poinsot  makes  a  fourth  variety 
of  the  case  of  Mons  which  I  have  placed  among  dislocations  of  both, 
bones  forward. 

A.  Antero-posterior. 

Excluding  Chevalier's  case,  of  which  I  have  no  details,  the  fourteen 
patients  were,  with  one  exception  (Tillaux),  males,  and  with  three 
exceptions,  adults ;  two  were  nine  years  old,  one  thirteen.  The  cause 
was  usually  a  fall  from  a  considerable  height,  or  with  violence,  as  from 
a  moving  railway  car,  a  horse,  or  a  wagon  ;  in  one  it  was  a  fall  while 
carrying  a  heavy  timber,  in  another  while  wrestling;  and  in  Tillaux's 
the  patient,  while  lighting  a  match,  struck  her  elbow  against  a  piece 
of  furniture  behind  her ;  the  pain  was  so  great  that  she  fainted  and 
fell  to  the  floor,  where  she  was  found  with  her  elbow  abducted  and 
flexed.  Scott's  patient  was  thrown  from  a  horse,  striking  upon  his 
head  and  hands ;  he  found  his  elbow  dislocated  and  the  forearm  partly 
flexed ;  a  bystander  pulled  it  straight,  and  he  felt  something  give  way 
in  the  joint,  and  a  bone  appeared  to  slip  forward;  possibly  a  disloca- 
tion of  the  ulna  alone  backward  was  thereby  transformed  into  the 
divergent  one  which  was  afterward  recognized.  Von  Pitha's  patient 
fell  head  foremost  from  the  second  story  of  a  building  upon  a  pile  of 
planks  between  which  the  extended  forearm  was  cauglit  and  held  while 
the  body  was  violently  precipitated  backward. 

Pingaud,*  experimenting  upon  the  cadaver,  found  it  easy  to  produce 
the  dislocation  by  forced  pronation  of  the  forearm  after  division  of 
the  internal  lateral  ligament ;  this  fact,  taken  in  connection  with  the 
fall  upon  the  hand  noted  in  several  of  the  cases,  indicates  that  the 

1  Bulley,  Provincial  Medical  and  Surgical  Journal,  1841,  quoted  in  the  Gazette  Medi- 
cale,  1841,  p.  666 ;  Michaux,  quoted  by  Debruyn  in  Annales  de  Cliir.  Franfaise  ct 
Etrangere,  1843,  vol.  ix.  p.  52;  Mayer,  Gazette  des  Hopitaux,  ]848,  p.  232;  Von  Pitha, 
Pithaand  Billroth's  Chirurgie,  4tli  vol.  2d  Abt.  B.  p.  78;  Chevalier,  Arch.  Med.  Beiges, 
October,  1870,  quoted  by  Bardeleben,  Chirurgie,  vol.  ii.  p.  759;  Gripat,  Bull,  de  la  Societe 
Anatomique,  1872,  p.  176;  .\rnozan,  Bordeaux  Med.,  1873,  p.  402,  quoted  by  Poinsot,  loc. 
cit.,  p.  945;  Tillaux,  Gazette  des  Hopitaux,  1877,  p.  786;  Minich,  Lo  Sperimentale,  1880, 
quoted  by  Poinsot;  Mason,  New  York  Medical  Record,  1880,  vol.  xvii.  p.  397;  Scott, 
Bristol  Medico-Chirurgical  Journal,  March,  1886,  p.  36 ;  Duret,  reported  by  Vanheu- 
verswyn.  Journal  des  Sc.  Med.  de  Lille,  Sept.  9,  1892  ;  Petzholdt,  Arch,  fiir  klin.  Chir., 
1894,  vol.  xlix.  p.  243;  Ferguson,  Hritisli  Medical  Journal,  April  6.  1895,  p.  753;  Bocken- 
heimer,  Miinch.  Med.  Wochshft.,  1911,  p.  2560. 

2  Guersant,  reported  by  Warniont  in  Revue  M6dico-Chirurgicale,  vol._  xvi,  p.  303, 
quoted  by  Pingaud  in  Diet.  Enfyclopedique,  art.  Coude,  p.  600,  and  by  Poiusot;  Wight, 
Physic,  and  Surgeon,  Ann  Arbor,  February,   1S93. 

3  Cooper:  Dislocations  and  Fractures,  American  edition,  p.  384. 
*  Pinguad:  Loc.  cit.,  p.  598. 


728  DISLOCATIONS. 

mechanism,  in  these  cases  at  least,  is  a  lateral  outward  flexion,  by 
which  the  internal  lateral  ligament  is  ruptured,  followed  or  accom- 
panied by  forcible  pronation,  and  then  by  the  direct  movement  down- 
ward of  the  humerus  between  the  two  bones.  Fracture  of  the  epi- 
trochlea  observed  in  one  case  (Arnozan)  supports  the  theory  of  outward 
lateral  flexion.  In  two  cases  (von  Pitha,  Gripat)  the  coronoid  process 
was  broken ;  in  both  the  fall  was  from  a  considerable  height. 

The  explanation  of  the  mechanism  in  the  two  cases  in  which  the 
injury  was  attributed  to  a  fall  upon  the  abducted  and  flexed  elbow 
(Michaux  and  Tillaux)  shares  in  the  difficulty  which  attaches  to  the 
explanation  of  dislocation  of  both  bones  backward  by  the  same  cause. 
If  the  alleged  rotation  of  the  ulna  backward  and  outward  around  the 
radius,  by  which  the  internal  lateral  ligament  is  torn,  is  accepted,  it 
will  not  be  difficult  to  conceive  that  the  radius  may  remain  in  front ; 
but  even  this  leaves  unexplained  the  forcible  descent  of  the  humerus 
between  the  two  bones  which  requires  the  rupture  of  the  annular  and 
interosseous  ligaments. 

In  Buret's  case  the  sigmoid  cavity  looked  outward  (supination),  and 
Vanheuverswyn  found  he  could  reproduce  this  form  upon  the  cadaver 
by  forced  supination  of  the  partly  flexed  forearm  after  division  of  the 
upper  part  of  the  interosseous  ligament. 

Pathology.  Two  of  the  patients  (von  Pitha,  Gripat)  died  of  the 
associated  injuries,  but  the  displacement  at  the  elbow  was  much  greater 
than  that  observed  in  the  other  cases. 

In  von  Pitha's  the  autopsy  showed  a  wide  separation  of  the  radius 
and  ulna  from  each  other,  complete  rupture  of  the  capsule,  and  of  the 
annular,  interosseous,  and  both  lateral  ligaments,  fracture  of  the  coro- 
noid process,  and  avulsion  of  the  biceps  and  brachialis  anticus. 

In  Gripat's  case,  a  boy  thirteen  years  old,  the  coronoid  process  had 
been  broken  off"  and  the  olecranon  had  passed  almost  directly  upward, 
remaining  close  to  the  posterior  surface  of  the  humerus ;  the  radius 
was  displaced  forward  and  outward.  The  internal  lateral  ligament 
had  been  torn  away  at  both  its  insertions;  the  external  one  remained 
attached  at  its  upper  insertion,  and  to  the  broken  coronoid  process  and 
part  of  the  anterior  ligament.  The  annular  ligament  was  torn  away 
at  its  posterior  attachment  to  the  ulna. 

Symptoms.  The  attitude  of  the  limb  is  noted  in  nine  cases ;  in  six 
it  was  slightly  flexed,  in  three  nearly  straight ;  in  one  case  supinated, 
in  the  others  midway  between  pronation  and  supination,  or  slightly 
pronated.  The  general  appearance  of  the  region  probably  resembles 
that  of  dislocation  of  both  bones  backward,  for  in  three  of  the  cases 
the  anterior  position  of  the  radius  was  not  noticed  until  after  the  ulna 
had  been  reduced.  Excluding  the  two  fatal  cases,  the  displacement 
of  the  ulna  upward  is  still  very  marked :  four  centimetres  in  Tillaux's 
case,  two  or  three  finger-breadths  in  Michaux 's,  and  one  and  a  half 
inches  above  the  condyles  in  Scott's  and  Ferguson's;  in  Tillaux's  it 
was  also  displaced  somewhat  to  the  inner  side.  In  four  cases  the 
position  of  the  radius  is  exactly  noted  ;  in  two  (Bulley,  Tillaux)  it 
was  in  the  coronoid  fossa  ;  in  Mason's  it  rested  on  the  outer  portion 
of  the  humerus ;  in  Petzholdt's  it  overlapped  the  inner  edge  of  the 
trochlea. 


DIVERGENT  DISLOCATIONS  OF   THE  ELBOW.  729 

Active  movements,  both  flexion  and  rotation,  are  impossible,  and 
passive  movements  restricted  and  painful. 

In  two  cases  (Mayer,  Tillaux)  reduction  failed,  the  attempt  being 
made  on  the  fourteenth  and  eighth  days  respectively.  In  both  the 
joint  remained  quite  stiff.  In  Mason's  the  attempt  was  made  on  the 
nineteenth  day  ;  prolonged  efforts  under  ether  brought  the  ulna  into 
place,  but  the  radius  slipped  toward  the  outer  side  and  could  not  be 
entirely  reduced.  The  final  result  is  not  known.  Bockenheimer  re- 
duced l:)y  operation.  In  the  others  reduction  was  effected  without  much 
difficulty,  usually  the  ulna  first,  then  the  radius,  but  in  Bulley's  the 
radius  remained  a  little  forward,  and  was  finally  reduced  by  continuous 
pressure  upon  it. 

Treatment.  Traction  should  be  made  in  the  direction  of  the  axis 
of  the  forearm  to  bring  the  ulna  into  place,  and  in  case  of  need  it 
might  be  well  to  combine  it  with  some  outward  lateral  flexion  to  avoid 
the  opposition  of  the  external  lateral  ligament ;  after  the  ulna  is 
reduced  the  radius  should  be  pressed  back  into  place  with  the  thumbs 
aided  by  pronation  and  adduction  of  the  forearm.  Possibly  the  return 
of  the  radius  may  be  impeded  by  the  torn  annular  ligament. 

B.  Transverse. 

Of  this  variety  there  are  only  two  recorded  cases.  Guersant's  is  as 
follows:  The  patient  was  a  boy  fifteen  years  old,  who  fell  from  a  tree, 
three  or  four  metres,  on  his  left  side,  striking  on  the  palm  of  his 
hand.  The  elbow  was  enormously  swollen  ;  the  transverse  diameter 
was  greatly  increased.  The  head  of  the  radius  formed  a  considerable 
prominence  entirely  to  the  outer  side  of  the  epi]'>hysis  of  the  humerus 
and  a  little  upward  along  its  outer  border.  It  was  so  far  displaced 
outward  that  there  seemed  to  be  an  interval  between  it  and  the  epi- 
condyle ;  the  skin  was  very  tightly  stretched  over  it. 

The  olecranon  was  displaced  inward  behind  the  epitrochlea,  which 
it  embraced  in  its  sigmoid  cavity.  In  the  great  space  between  the 
olecranon  and  radius  lay  almost  the  entire  articular  surface  of  the 
humerus. 

The  forearm  was  semi-flexed,  and  in  a  position  midway  between  pro- 
nation and  supination  ;  voluntary  movements  were  impossible,  passive 
movements  very  restricted.  There  was  also  a  fracture  of  the  forearm 
three  centimetres  from  the  wrist. 

Wight's  patient  was  a  woman  thirty  years  old,  who  had  fallen  while 
walking,  the  pronated  right  arm  being  caught  under  the  body.  Sup- 
posing tiie  injury  to  be  a  backward  dislocation  he  attempted  to  reduce 
under  ether,  and  after  failing  made  a  closer  examination.  He  then 
found  that  the  radius  was  on  the  outer  and  the  ulna  on  the  inner  side 
of  the  humerus.  No  other  details.  He  reduced  the  radius  by  press- 
ing on  its  head  while  making  traction  and  adduction,  and  then  the 
ulna  by  traction  and  adduction  (abduction  ?),  "  using  the  external  con- 
dyle as  a  fulcrum,  and  at  the  same  time  firmly  flexing  the  elbow." 


CHAPTEK  XLVI. 

DISLOCATIONS  OF  THE  ELBOW.— (Continued.) 

Isolated  Dislocations  of  the  Ulna  and  Radius. 

DISLOCATIONS    OF    THE    ULNA    ALONE. 

Sedillot,  in  a  paper  presented  to  the  Academic  des  Sciences  in  1837, 
was  the  first  of  modern  writers  to  call  attention  to  this  class  of  dislo- 
cations, although  Sir  Astley  Cooper  had  previously  described  as  of 
this  kind  a  specimen  preserved  at  St.  Thomas's  Hospital.  Malgaigne 
and  other  surgeons  and  writers  strenuously  opposed  the  interpretation 
of  cases  cited  in  support  of  the  claim  that  the  occurrence  of  this  form 
is  possible,  and  denied  the  possibility  on  anatomical  grounds,  claiming 
that  the  ulna  cannot  be  displaced  backward  and  upward  unaccompanied 
by  the  radius,  except  after  rupture  of  the  interosseous  ligament  and 
those  uniting  the  lower  ends  of  the  bones,  of  which  there  is  no  clinical 
evidence.  The  specimen  figured  and  described  by  Cooper  is  claimed 
by  them  to  be  one  of  dislocation  backward  of  both  bones,  and  one 
presented  by  Robert  to  the  Soci^t^  de  Chirurgie,  in  1847,  was  declared 
by  Malgaigne  to  be  of  the  same  character.  I  have  examined  Cooper's 
specimen,  which  is  still  preserved  at  St.  Thomas's  Hospital,  and  have 
no  doubt  that  it  is  simply  an  old  unreduced  backward  dislocation 
of  both  bones,  the  error  in  interpretation  having  been  due  to  a  failure 
to  appreciate  the  new  formation  of  bone  behind  the  external  condyle. 
Malgaigne  admits,  however,  on  the  authority  of  a  case  observed  by 
himself,  the  possible  dislocation  of  the  ulna  alone  backward  and  to  the 
outer  side  behind  the  radius.  The  dispute  is  in  part  one  of  terms ;  it 
must  be  admitted,  I  think,  that  the  head  of  the  radius  in  some  of 
the  reported  cases  has  changed  its  relations  with  the  capitellum,  but 
the  change  is  a  very  slight  one,  a  simple  slipping  backward  or  forward 
for  a  distance  of  a  few  millimetres,  without  a  change  in  its  level  corre- 
sponding to  that  of  the  ulna.  The  erroneous  belief  in  the  impossibility 
of  the  occurrence  without  the  extensive  lacerations  mentioned  arose 
apparently  from  a  failure  to  consider  the  effect  of  a  change  in  the  rela- 
tion of  the  axes  of  the  arm  and  forearm,  for  while  the  occurrence  of 
an  isolated  dislocation  of  the  ulna  backward  and  upward  might  be 
impossible  while  those  relations  remained  unchanged,  yet  if,  the  joint 
being  extended,  the  forearm  is  adducted,  turning  upon  the  head  of 
the  radius  as  a  centre,  the  olecranon  must  necessarily  move  upward 
behind  the  humerus ;  or,  the  joint  being  flexed  at  a  right  angle,  the 
same  movement  of  adduction  will  displace  the  olecranon  backward ; 
in  like  manner  abduction  of  the  forearm  can  bring  the  olecranon  for- 
ward or  downward. 
(730) 


DISLOCATIONS  OF  THE   ULNA  ALONE. 


'31 


The  following  recorded  cases '  serve  as  a  basis  of  the  description  to 
be  given.  Some  in  which  the  correctness  of  the  diagnosis  is  in  doubt, 
or  of  whicli  I  have  not  been  able  to  consult  the  detailed  reports,  have 
been  omitted. 


Fig.  422. 


1.  Backward  Dislocation. 

Backward  dislocation  presents  itself  under  three  forms.  In  the 
first,  that  in  which  the  displacement  is  slightest,  the  ulna  is  carried 
backward,  either  directly  or  by  inward  rotation  of  the  forearm  about 
the  radius  as  a  centre,  until  the  coronoid  process  has  cleared  the 
trochlea,  and  then  is  moved  slightly  upward  behind  it  by  adduction 
of  the  forearm  (Fig.  422);  in  the  second  form,  the  movement  upward 
is  prolonged  until  the  coronoid  process  lodges  in  the 
olecranon  fossa  ;  in  the  third,  the  primary  movement 
of  rotation  is  prolonged  until  the  olecranon  lies  behind 
the  radius.  The  first  form  is  the  most  common,  and 
is  sometimes  termed  "  incomplete,"  in  accordance 
with  a  similar  use  of  the  term  in  the  backward  dis- 
location of  both  bones ;  of  the  third  form  there  are 
only  three  recorded  examples  (Malgaigne,  Wilson, 
Warbasse).  Some  writers  make  an  additional  variety, 
dislocation  backward  and  inward,  a  distinction  which 
it  does  not  seem  necessary  to  preserve. 

Cause.  The  cause  in  the  larger  number  of  cases 
has  clearly  been  a  fall  upon  the  outstretched  hand ; 
in  one,  Brun,  a  blow  received  upon  the  elbow  from 
behind  while  the  w^eight  of  the  body  rested  upon  the 
extended  arm. 

In  von  Pitha's  case  the  injury  was  received  in  such 
a  way  that  the  mode  of  production  is  clearer  than  in 
most  accidents,  and,  as  the  case  is  typical  in  other  re- 
spects, I  reproduce  the  account. 

A  girl  six  years  old  and  her  little  brother  were 
engaged  in  a  trial  of  strength,  in  which  each  sought 
to  move  an  open  door  against  th<i  other's  opposition, 
the  girl  standing  with  her  back  against  the  wall  and  her  out- 
stretched hands  against  the  door,  the  hinges  being  at  her  left  side. 
Two  other  brothers  came  to  the  help  of  the  first,  and  under  their  com- 
bined efforts  the  girl's  left  arm  suddenly  doubled  up  with  an  audible 
snap,  and  when  von  Pitha  examined  it  half  an  hour  later,  he  found 
"the  most  distinct  picture  of  a  dislocation  of  the  ulna  backward." 
The  thin  arm  was  in  almost  complete  extension,  the  forearm  being 

1  Boudant,  Revue  Medicale,  1830,  vol.  i.  p.  85,  quoted  in  full  by  Sedillot;  Sedillot.Gazotte 
Medicale,  1839,  vol.  vii.  p.  369 ;  Diday,  idem,  p.  393  :  Brun  (three  cases),  idem,  1844,  p.  oSO ; 
Robert,  Gazette  des  Hopitaux,  1847,  p.  272  ;  von  Pitha,  Pitha  and  Billroth's  Chirurjiie, 
vol.  iv.  part  ii.  B,  p.  87;  Malgaigne,  Luxations,  p.  631;  Duguet,  Bulletins  de  la  Societ6 
Anatomique,  1863,  p.  278;  Mathieu,  Gazette  des  Hopitaux,  1866,  p.  330;  Waterman,  Bos- 
ton Medical  and  Surgical  Journal,  1869,  vol.  Ixxxi.  p.  187;  Wilson,  Canada  Journal  of 
the  Medical  Sciences,  1880,  vol.  v.  p.  .346;  W^aters,  Maryland  Medical  Journal.  18S3,  vol. 
X.  p.  402 ;  Warbasse,  Annals  of  Surg.,  Aug.,  1910,  p.  215  ;  Loison,  Arch,  de  IMed.  et  Pharni. 
Mil.,  September,  1890,  inward;  Wi^ht.  Brooklyn  ^^ledical  Journal,  September,  1889;  and 
Stimson,  case  here  giyen,  both  forward. 


Dislocation  of  ulna 
alone  backward,  first 
form.    (SfeDiLLOT.) 


732  DISLOCATIONS. 

slightly  inclined  toward  the  ulnar  side  ;  the  fold  of  the  elbow  was  some- 
what raised  by  the  projecting  trochlea ;  the  olecranon  was  very  promi- 
nent behind,  but  barely  raised  above  its  normal  level ;  the  elbow  was 
notably  thicker,  but  not  broader ;  the  head  of  the  radius  was  in  its 
place ;  pronation  and  supination  were  but  slightly  restricted,  but  the 
least  movement  of  flexion  was  very  painful.  Reduction  was  easily 
accomplished  by  grasping  with  the  left  hand  the  humerus  above  the 
condyles,  and  with  the  right  the  forearm  in  such  a  way  that  the  thumb 
and  fingers  specially  compressed  the  ulna,  and  then  supinating,  abduct- 
ing, and  extending  until  there  was  slight  dorsal  flexion  ;  at  this  moment 
he  distinctly  felt  the  lifting  of  the  coronoid  process,  and  on  increasing 
the  traction  it  suddenly  slipped  back  over  the  trochlea  with  a  snap. 
Pain  at  once  ceased,  and  the  patient  could  flex  the  joint. 

Experiments  upon  the  cadaver  by  Sedillot  and  Streubel  ^  indicate 
that  the  mode  of  production  is  similar  to  that  of  backward  dislocations 
of  both  bones  together — that  is,  the  forearm  is  abducted  (Streubel)  or 
hyperextended  (Sedillot)  until  the  internal  lateral  ligament  yields,  and 
then  rotated  inward  and  adducted  to  carry  the  coronoid  process  past 
the  trochlea  and  engage  its  point  against  the  posterior  surface  of  the 
latter.  If  the  adduction  is  increased,  and  es])ecially  if  at  the  same 
time  the  orbicular  ligament  is  torn,  the  olecranon  rises  to  a  higher  point 
and  may  pass  to  the  inner  side.  If,  on  the  other  hand,  adduction  is 
absent  and  the  rotation  is  prolonged,  the  olecranon  is  carried  around 
behind  the  radius,  and  the  form  is  produced. 

Pathology.  Two  specimens  (Robert,  Duguet)  and  one  compound 
dislocation  (Boudant)  furnish  but  scanty  information  of  the  patholog- 
ical details,  for  which  we  must  mainly  depend  upon  experiment.  Of 
the  two  specimens,  Robert's  alone  was  of  a  recent  case. 

Duguet's  specimen  was  taken  from  a  man,  fifty  years  old,  who  had 
received  the  injury  twenty  years  previously.  There  was  anchylosis  in 
the  extended  position,  but  pronation  and  supination  were  preserved. 
The  ulna  was  displaced  backward  and  upward  so  that  its  upper  end 
was  two  centimetres  above  the  line  uniting  the  two  epicondyles,  and  a 
nearthrosis  had  formed  between  the  tip  of  the  olecranon  and  the  back 
of  the  humerus  above  and  a  little  to  the  inner  side  of  the  olecranon 
fossa.  It  is  probable,  therefore,  that  the  coronoid  process  was  lodged 
in  the  olecranon  fossa.  Concerning  the  radius  two  statements  are  made  : 
the  first  is  that  it  had  preserved  its  relations  with  the  external  condyle  ; 
the  second,  that  it  was  appreciably  displaced  forward,  and  preserved 
its  movements  of  rotation.  I  understand  these  to  mean  that  the 
head  was  directly  below  the  condyle  and  a  little  in  front  of  the 
position  it  would  normally  occupy  in  that  attitude  (extension  of  the 
limb). 

In  Robert's  case  the  injury  was  caused  by  a  fall  on  the  palm  of  the 
hand  ;  the  limb  was  partly  flexed,  the  olecranon  prominent  posteriorly 
and  elevated ;  the  head  of  the  radius  could  not  be  felt  because  of  the 
swelling,  but  it  could  be  moved  backward  and  forward  with  cartilagi- 
nous crepitus.  At  the  autopsy  the  coronoid  process  was  found  in  the 
olecranon  fossa,  and  the  radius  in  place;  the  humerus  appeared  to  have 

*  streubel :  Prager  Vierteljahrschrift,  1850,  ii.  p.  54. 


DISLOCATIONS  OF  THE   ULNA  ALONE.  733 

been  twisted  so  that  its  anterior  aspect  looked  outward  (in  other  words, 
the  forearm  was  adducted) ;  the  annular  ligament  and  some  of  the  fibres 
of  the  external  lateral  ligament  were  torn.  The  condition  of  the  inter- 
nal lateral  ligament  is  not  mentioned.  The  brachialis  anticus  and 
brachial  artery  were  ruptured. 

Boudant's  patient  was  a  man  forty-nine  years  old,  who  had  fallen 
from  the  first  story  of  a  building  and  received  a  compound  dislocation  ; 
the  wound  was  eighteen  or  twenty  lines  in  length  on  the  inner  and 
anterior  part  of  the  elbow,  and  was  thought  to  have  been  caused  by 
contact  with  a  large,  rough  stone.  It  seems,  however,  not  unlikely 
that  it  was  caused  from  within  outward  by  the  pressure  of  the  trochlea 
in  hyperextension  of  the  joint.  The  olecranon,  which  was  prominent 
posteriorly,  could  be  seen  through  the  wound,  and  the  finger  introduced 
into  the  latter  recognized  the  radius  in  place.  Reduction  was  easy,  and 
the  patient  made  a  good  recovery. 

The  experiments  made  upon  the  cadaver  show  that  the  internal 
lateral  ligament  is  always  ruptured,  and  that  the  orbicular  ligament 
escapes  injury  if  the  displacement  is  not  great. 

Symptoms.  In  the^rs^  and  second  forms,  dislocation  backward  and 
upward,  the  limb  is  usually  in  almost  complete  extension  (in  Duguet's 
and  Waterman's  cases  it  was  flexed  at  a  right  angle),  and  cannot  be 
flexed  without  causing  much  pain,  but  pronation  and  supination  are 
free  and  painless.  The  normal  deflection  of  the  forearm  toward  the 
outer  side  is  lost,  and  in  its  place  may  be  a  deflection  toward  the  ulnar 
side.  This  deflection  is  easily  recognized  by  the  eye  when  the  limb  is 
extended,  but  when  the  joint  is  flexed  at  or  near  a  right  angle  it  may 
be  overlooked  unless  comparative  measurements  are  made ;  in  Diday's 
case  the  length  of  the  ulnar  border,  from  the  epitrochlea  to  the  lower 
end  of  the  ulna,  was  an  inch  shorter  than  that  of  the  other  arm,  while 
the  radial  borders  were  of  equal  length.  The  antero-posterior  diameter 
of  the  joint  is  increased,  and  the  fold  of  the  elbow  is  filled  out  by  the 
trochlea. 

The  olecranon  is  prominent  behind  the  humerus,  and  may  rise  well 
above  the  line  of  the  epicondyles ;  it  may  be  nearer  tlie  epitrochlea 
than  usual.  The  head  of  the  radius  can  be  felt  in  its  place,  and  it  is 
by  the  determination  of  this  fact,  together  with  the  displacement  of  the 
olecranon,  that  the  diagnosis  of  the  variety  of  the  dislocation  is  made. 

In  the  three  recorded  cases  of  the  third  form,  dislocation  of  the  ulna 
backward  and  outward  behind  the  radius,  the  elbow  was  flexed  nearly 
at  a  right  angle.  In  Malgaigne's  the  forearm  was  pronated  and  deviated 
outward ;  the  greater  sigmoid  cavity  was  directed  outward  {sic),  the 
coronoid  process  outward  and  forward.  Reduction  was  easy.  In 
^^^arbasse's  the  elbow  was  fixed  at  150  degrees,  rotation  restricted  to 
one-fourth. 

Treatment.  In  Duguet's  case  reduction  was  not  made  ;  in  the  others 
it  was  easily  obtained.  Waterman  tried  Cooper's  method  of  the  knee 
in  the  elbow,  and  Skey's  of  traction  upon  the  upper  part  of  the  flexed 
forearm  in  the  line  of  the  humerus,  without  success,  and  then  easily 
reduced  by  hyperextension.  The  readiest  method  in  the  first  and 
second  forms  appears  to  be  that  employed  by  von  Pitha,  and  described 


734  DISLOCATIONS. 

above — supination,  abduction,  and  liyperextension  of  the  forearm. 
Malgaigne  and  Wilson  reduced  (third  form)  by  direct  pressure  upon 
the  olecranon,  first  backward  to  free  it  from  the  radius,  and  then  in- 
ward ;  Warbasse  by  arthrotomy. 

(A  case  described  by  Richet,^  as  a  new  kind  of  dislocation  by  rota- 
tion, seems,  from  its  title  and  from  some  of  its  features,  to  belong  to 
this  class,  but  the  account  is  so  incomplete  that  it  is  not  available.) 

2.  Dislocation  Inward. 

Of  this  there  is  only  one  reported  case,  Loison's.  The  patient,  a 
man  t^venty-four  years  old,  fell  backward  upon  the  left  elbow,  bruising 
the  skin  on  the  inner  side  an  inch  below  the  epitrochlea;  the  wounds 
suppurated ;  the  diagnosis  was  not  made  until  the  forty-second  day. 
Then  the  radius  was  found  in  place,  and  the  olecranon  displaced  inward 
so  that  the  sigmoid  cavity  embraced  the  epitrochlea.  Four  months 
after  the  accident,  reduction  not  having  been  made,  the  limb  could  be 
actively  flexed  to  80  degrees  and  extended  to  135  degrees;  rotation 
apparently  well  preserved. 

3.  Dislocation  Forward. 

March  13,  1895,  I  saw  at  the  Hudson  Street  Hospital  a  man  thirty- 
five  years  old,  who  had  injured  his  right  elbow  in  falling  backward, 
the  arm  being  caught  under  him.  As  he  complained  of  handling  I 
gave  ether.  The  following  notes  were  made  at  the  time  :  The  elbow 
is  held  at  a  right  angle,  but  can  be  somewhat  flexed  and  extended  ;  is 
movable  laterally.  The  epitrochlea  can  be  plainly  felt,  also  the  inner 
face  and  edge  of  the  trochlea,  the  overlying  flexor  muscles  of  the  hand 
having  been  torn  aAvay  from  the  humerus.  The  tip  of  the  olecranon 
is  below  and  even  a  little  in  front  of  the  trochlea,  the  inner  anterior 
portion  of  the  articular  surface  of  which  can  also  be  felt  on  depressing 
the  skin.  The  head  of  the  radius  is  in  place  in  front  of  the  capitellum. 
The  forearm  is  markedly  abducted. 

Reduction  was  easily  made  by  slight  rotation  backward  (pronation) 
of  the  ulna  and  adduction  of  the  forearm.  Then  by  pronation  and 
abduction  the  dislocation  could  be  easily  reproduced.  When  the  bones 
were  in  place  abduction  of  the  forearm  was  possible,  but  not  adduction. 
Apparently  the  lesions  were  avulsion  of  the  flexor  muscles  from  the 
humerus  and  rupture  of  the  internal  lateral  ligament.  The  ulnar 
nerve  was  uninjured. 

The  only  other  reported  case  is  Wight's  ;  the  symptoms  were  similar, 
and  reduction  was  easily  made. 

DISLOCATIONS  OF   THE  RADIUS  ALONE. 

Although  statistics  show  that  these  dislocations  are  not  very  rare  (1.4 
to  4  per  cent,  in  the   tables  in   Chapter  XXVII. ),  and  although  the 

'  Richet:  Nouveau  genre  de  luxation  incomplete  du  coude  par  pivotement.     Gazette 
des  Hopitaux,  1879,  p.  737. 


DISLOCATIONS  OF  THE  RADIUS  ALONE.  735 

earliest  writers  mentioned  them,  yet  they  were  almost  completely  lost 
sight  of  until  about  one  hundred  and  fifty  years  ago,  and  even  now 
are  far  from  being  clearly  understood.  Duverney,  in  1751,  gave  a 
detailed  account  of  two  forms.  Since  that  time  observations  have 
accumulated,  and  four  varieties  are  now  well  established — the  dislo- 
cations forward,  backward,  and  outward,  and  one  seen  exclusively  in 
children,  and  caused  by  traction  upon  the  wrist,  the  nature  of  which, 
though  not  entirely  undisputed,  is  generally  believed  to  be  a  diastasis 
or  direct  separation  ;  it  is  usually  termed  dislocation  by  elongation. 

Tlie  mode  of  production  of  all  the  forms  is  still  obscure,  and  the 
numerous  experiments  that  have  been  made  upon  the  cadaver  by  vari- 
ous investigators,  Roser,  Malgaigne,  Streubel,  Denuce,  Pingaud,  Barros, 
while  they  have  shown  how  the  dislocations  may  be  produced  upon  the 
cadaver,  have  not  made  it  clear  how  they  actually  are  produced  in  the 
patients  who  come  under  observation  ;  in  some  cases  the  clinical  facts 
directly  contradict  the  conclusions  drawn  from  experiment. 

1.  Dislocation  Backward. 

This  was  one  of  the  forms  described  by  Duverney,  and  one  of  the 
earliest  to  be  accepted  as  proved  by  later  surgeons.  Its  apparent  fre- 
quency is  in  part  due  to  the  inclusion  in  the  list  of  reported  cases  of 
those  in  which  the  dislocation  is  associated  with  fracture  of  the  internal 
condyle,  and  probably  also  of  others  which  belong  in  the  group  of  dis- 
locations by  elongation.  Two  varieties  are  described,  the  complete  and 
the  incomplete,  the  latter  resting  upon  a  few  questionable  and  one 
well-observed  case,  that  of  Denuce  :  ^  a  lad  nineteen  years  old  fell  from 
a  swing,  his  pronated  arm  being  caught  under  his  body  in  such  a  way 
that  the  blow,  as  shown  by  an  ecchymosis,  was  received  upon  the 
middle  of  the  anterior  aspect  of  the  forearm.  Pain ;  limitation  of 
motion ;  the  elbow  semiflexed,  the  forearm  fixed  in  complete  prona- 
tion. A  bone-setter  tried  in  vain  to  reduce  it,  and  a  fortnight  later 
the  patient  consulted  Denuce,  who  found  "  behind  the  elbow,  on  a  level 
with  the  condyle,  and  to  the  inner  side  of  the  epicondyle,  a  small  promi- 
nent tumor,  which  rolled  under  the  finger  in  pronation,  and  was  evi- 
dently the  head  of  the  radius,  a  little  overlapping  its  ordinary  position 
posteriorly." 

Of  the  complete  cases  the  instances  are  much  more  numerous,  but 
in  some  of  them  the  question  arises  whether  the  upper  surface  of  the 
radius  had  entirely  left  the  articular  surface  of  the  capitellum,  or  was 
still  in  contact  with  it  by  its  anterior  portion  ;  if  such  contact  did  exist, 
the  term  "complete"  can  be  properly  applied  only  to  the  separation 
of  the  radius  from  the  lesser  sigmoid  cavity  of  the  ulna. 

The  cause,  in  the  majority  of  cases,  appears  to  have  been  a  fall  upon 
the  outstretched  hand  ;  that  the  cause  was  a  fall  in  most  cases  is  certain, 
but  whether  it  was  upon  the  hand  or  the  elbow  is  often  far  from  clear, 
or  whether  it  acted  by  direct  impulsion  or  by  exaggerated  rotation. 

In  a  case  reported  by  Cameron  ^  the  character  and  mode  of  action  of 
the  violence  are  more  clearly  shown  than  usual,  but  they  are  entirely 

^  Demice  :  Diet,  de  Mi'd.  et  Chir.  pratiques,  art.  Coude,  p.  777. 
2  Cameron  :  Laucet,  1884,  vol.  i.  p.  885. 


736  I>ISL  OCA  TIOXS. 

exceptional,  and  the  case  does  not  aid  to  clear  up  the  obscurity  in  which 
the  question  is  enveloped.  The  patient  was  a  man  fifty-two  years  old, 
who  was  caught  between  a  wall  and  a  cart  l)acking  against  it  in  such  a 
way  that  his  forearm  was  compressed  lengthwise  between  them,  the 
palm  of  the  hand  being  pressed  against  the  cart,  and  the  back  of  the 
elbow  against  the  wall ;  probably  the  hand  was  completely  pronated. 
When  seen,  immediately  after  the  accident,  the  head  of  the  radius  lay 
just  under  the  skin  behind  the  external  condyle,  where  it  formed  a 
distinct  projection,  revealing  to  the  eye  its  characteristic  shape  with  the 
cavity  on  its  extremity.  The  hand  and  forearm  were  prone ;  all  move- 
ments were  painful,  and  gave  the  impression  of  considerable  fixity  of 
the  joint.  Pain  at  the  wrist  led  to  an  examination,  which  showed 
that  "  the  styloid  extremity  was  also  dislocated  downward,  exactly  as 
in  cases  in  which  the  radius  is  shortened  by  the  common  fracture  of 
its  lower  extremity." 

AYhile  the  character  of  the  force  and  the  direction  of  its  action  in 
this  case  are  clear,  pressure  exerted  against  the  lower  end  of  the  radius 
in  the  line  of  its  long  axis,  yet  it  is  far  from  being  clear  how  such  a 
force,  so  applied,  could  produce  such  a  displacement,  for  the  head  of  the 
radius  is  squarely  placed  against  the  anterior  face  of  the  capitellum, 
not  upon  an  inclined  surface  along  which  it  could  be  displaced.  And 
yet,  that  there  is  something  in  the  anatomical  structure  of  the  joint 
which  permits  the  occurrence  and  forbids  the  rejection  of  the  case  on 
the  supposition  of  abnormal  conditions,  is  indicated  by  the  fact  that 
two  similar  cases  have  been  reported  by  Wagner,^  in  which  the  mode 
of  production  was  the  same  as  in  Cameron's,  but  the  head  of  the  radius 
was  displaced  to  the  outer  side  of  the  condyle  instead  of  behind  it, 
and  a  flat,  wedge-shaped  piece  was  broken  off'  its  inner  side. 

Streubel,^  in  his  experiments  upon  the  cadaver,  found  that  he  could 
produce  the  dislocation  in  only  one  way,  by  hyperextending  the  supi- 
nated  forearm  until  the  head  of  the  radius  had  been  carried  completely 
behind  the  line  of  the  condyle,  then  forcing  it  upward,  and  at  the  same 
time  bending  the  forearm  to  the  radial  side,  and  finally  flexing  it  again 
while  holding  the  radius  pressed  firmly  back  with  the  thumb  of  the  hand 
that  grasped  the  forearm.  It  is  by  no  means  probable  that  this  rather 
complicated  manoeuvre,  which,  moreover,  has  entirely  failed  in  my 
hands,  is  a  reproduction  of  what  has  taken  place  in  the  falls  that  have 
produced  the  dislocation.  The  radius  is  dislocated  not  only  from  the 
humerus,  but  also  from  the  ulna,  and  this  requires  the  rupture  of  the 
orbicular  ligament.  To  effect  that,  something  more  is  required  than 
hyperextension  of  the  elbow,  even  with  the  addition  of  direct  propul- 
sion upward  of  the  radius.  Supination  of  the  forearm  will  not  effect 
it,  and  while  direct  propulsion  backward  of  the  bone  would  undoubt- 
edly produce  the  dislocation,  the  clinical  facts  do  not  indicate  this  as 
the  cause.  Possibly  in  hyperextension  and  outward  lateral  flexion,  as 
in  Streubel's  experiments,  the  head  of  the  radius  may  become  engaged 
behind  the  slight  projection  of  the  articular  surface  of  the  capitellum 
at  the  bottom  of  the  condyle,  and  be  thereby  prevented  from  accom- 

1  Wagner  :   Beilage  zvini  Centralblatt  fiir  C'hirurgie,  1886,  No.  24,  p.  93 
*Streubel  :  Prager  Vierteljahrscbrift,  1850,  vol.  ii.  p.  68. 


DISLOCATIONS  OF  THE  RADIUS  ALOXE. 


737 


panying  the  ulna  in  its  return  forward  when  the  elbow  is  again  flexed ;  this 
would  supply  the  strain  necessary  to  separate  tlie  radius  from  the  ulna, 
but  I  must  add  that  all  the  attempts  I  have  made  thus  to  produce  the  dis- 
location were  fruitless  ;  the  result  was  always  a  dislocation  of  both  bones. 

There  are  no  post-mortem  records  of  recent  cases,  and  the  dissection 
of  those  of  long  standing  is  not  an  entirely  trustworthy  indication  of 
the  condition  and  the  rehitions  of  the  parts  when  the  injury  is  fresh. 
A  case  observed  by  Mr.  Rivington^  is  of  particular  importance,  because 
the  position  of  the  head  is  more  exactly  noted  than  is  usual  in  the 
descriptions.  The  patient  was  a  lad  fourteen  years  old,  and  the  injury 
liad  been  received  five  months  previously  in  a  scuffle,  during  whicli  he 
was  violently  shaken  by  the  forearm,  and  thrown  chnvn,  strikino-  his 
elbow  against  the  leg  of  a  table.  There  was  a  marked  prominence 
"at  the  back  of  the  joint  below  the  external  condyle,  and  by  the  side 
of  the  olecranon  process."  "  The  head  of  the  radius  was  displaced 
more  directly  backward  than  is  usual,  according  to  the  descriptions  of 
the  books,  not  lying  in  any  wise  beliind  the  external  condyle,  but  a 
little  overlapping  the  articular  end  of  the  humerus."  Flexion  and 
extension  were  almost  unimpaired,  pronation  was  good,  and  supination 
to  more  than  half  the  usual  extent.     Reduction  failed. 

In  a  specimen  of  an  old  dislocation,  which  had  been  received  in  child- 
hood and  had  existed  for  many  years,  presented  by  Petit ^  to  the  Societe 
Anatomique,  the  head  of  the  radius  was  directly  below  the  summit  of 
the  e})icondyle  when  the  elbow  was  flexed  at  a  right 
angle.  In  another  specimen  found  in  the  dissect- 
ing-room and  described  and  figured  by  Sir  Astley 
Cooper,  "  the  head  of  the  radius  could  be  seen,  as 
well  as  felt,  behind  the  external  condyle  of  the  os 
humeri.  The  coronary  ligament  was  torn  through 
at  its  forepart,  and  the  oblique  had  given  way. 
The  capsular  ligament  was  partially  torn,  and  the 
head  of  the  radius  would  have  receded  still  more, 
had  it  not  been  supported  by  the  fascia  which 
extends  over  the  muscles  of  the  forearm.  The 
accompanying  figure  (Fig.  423)  indicates  that  the 
head  of  the  radius  had  risen  very  slightly  above 
the  lowest  part  of  the  articular  portion  of  the  con- 
dyle, and  that  its  position  was  probably  the  same 
as  in  Mr.  Rivington's  case. 

In  another  specimen  of  old  dislocation  presented 
to  the  Societe  de  Chirurgie  by  Bernadet,^  the  head 
of  the  radius  had  been  displaced  a  little  backward, 
downward,  and  outward ;  the  external  lateral  liga- 
ment entirely  covered  the  cup-shaped  surface  of 
the  head;  the  annular  ligament  no  longer  existed 
except  upon  the  inner  side,  and  there  it  was  notably  tliickciicd  and 
obliquely  deviated. 

1  Rivington  :  Lancet,  1879,  vol.  ii.  p.  942. 

2  Petit :   Bull.  (Ic  la  Sofii'te  Aiiati)mi(iiic.  I"-?  1,  ]<.  901. 

3  Bcrnadet:  Bull,  de  la  .Soc.  de  t'hir.,  1801,  p.  4(J-J. 


Fig.  423. 


Dislocation  of  the 
head  of  the  radius- 
backward.  (Cooper.) 


738 


DISLOCATIONS. 


In  the  specimens  which  Streubel  obtained  by  experiment  he  always 
found  the  anterior  portion  of  the  capsule  torn  and  the  capitellum 
projecting  through  the  rent ;  the  external  lateral  ligament  was  more  or 
less  torn  at  its  anterior  border,  the  internal  lateral  ligament  uninjured ; 
the  annular  ligament  was  always  torn  in  front,  either  at  its  insertion 
by  the  lower  sigmoid  cavity,  or  further  outward  ;  the  oblique  ligament 
was  torn,  doubtless  in  consequence  of  the  exaggerated  supination. 

These  facts,  though  not  numerous  or  entirely  free  from  objection, 
indicate  that  the  position  of  the  dislocated  head  of  the  radius,  even  in 
full  extension,  is  lower  than  that  commonly  assigned  to  it  in  systematic 
descrintions  and  shown  in  the  plates  accompanying  them— that  it  does 
not  rise  above  the  shallow  groove  which  marks  the  posterior  and  lower 
margin  of  the  articular  surface  of  the  capitellum.  At  this  point  the 
upper  margin  of  the  head  would  be  but  very  Httle  below  the  axis  of  the 
joint,  and  consequently  would  have  to  move  over  only  a  short  distance 
in  full  flexion  and  extension  of  the  limb. 

Fig.  424. 


Excessive  growth  in  length  of  the  radius  after  dislocation  of  its  upper  end  in  youth. 

A  unique  case  of  great  elongation  of  the  radius  after  dislocation  was 
communicated  to  me  by  Dr.  J.  C.  Larkin,  of  Hillsboro,  Ohio,  in  1912. 
The  patient,  forty  \'ears  old,  had  injured  his  elbow  when  two  years  old. 
l)uriii,<>;  youth  the  radius  gradually  lengthened  until  its  head  stood  out 
one  and  a  half  inches  behind  the  elbow,  as  shown  in  Fig.  424.    During 


DISLOCATIONS   OF  THE  RADIUS  ALONE. 


739 


adult  life  there  had  been  but  little,  if  any,  growth.  The  shaft  lav 
beneath  the  external  condyle.  Flexion  and  extension  good,  rotation 
much  restricted,  arm  useful.  The  patient  sought  relief  from  the  con- 
stant chafing  of  the  skin  over  the  head.  Dr.  Larkin  removed  the  pro- 
jecting bone. 

In  recent  cases  the  elbow  is  slightly  flexed,  the  forearm  pronated  ; 
voluntary  and  communicated  movements  are  painful  and  limited  in 
range,  but  in  old  cases  the  freedom  of  motion  is  almost  completelv 
restored,  supination  remaining  the  most  imperfect.  Tiie  diagnosis  is 
made  by  recognition  of  the  head  of  the  radius  behind  its  normal  place 

Fig.  425. 


Excessive  growth  in  length  of  the  radius  after  dislocation  of  its  upper  end  in  youth. 

in  extension,  behind  and  below  it  in  flexion  at  a  right  angle.  It  may 
lie  close  beside  the  olecranon  or  further  to  the  outer  side.  Its  projec- 
tion, unless  the  swelling  is  considerable,  is  such  that  the  entire  extent 
of  its  concave  upper  surface  can  be  felt.  Measurement  of  the  radial 
border  of  the  forearm  from  tiie  epicondyle  to  the  styloid  process  of  the 
radius  mav  show  some  shortening,  half  an  inch  according  to  Streulicl. 
Treatment.  Tlie  dislocation  in  recent  cases  has  usually  been  reduced 
promptly  by  pressure  on  the  head  of  the  radius,  aided  or  not  by  trac- 
tion upon  the  wrist,  and  this  method  has  succeeded  even  when  several 
M-eeks  had  passed  since  tiie  receipt  of  the  injury,  liut  in  some  eases 
reduction  has  been  impossible  or  the  disj)laeement  has  shown  a  marked 
tendency  to  recur,  botli  circumstances  prolxibly  due  in  the  recent  cases 


740 


DISLOCATIONS. 


to  the  interposition  of  a  portion  of  the  capsule,  but  in  the  older  ones 
also  to  permanent  change  in  the  relations  of  the  shafts  of  the  radius 
and  ulna  and  to  adhesions  between  them.  This  interposition  of  the 
capsule  has  been  demonstrated  in  one  or  two  cases  in  which  arthrotomy 
has  been  done  (see  Chapter  XLVII.)-  Probably  the  best  position  to 
give  the  limb  during  the  attempt  is  that  of  supination  and  full  exten- 
sion, and  if  direct  pressure  does  not  then  restore  the  bone  to  its  place 
traction  should  be  made  at  the  wrist,  and  the  forearm  gradually  bent 
to  the  inner  side,  and  then  the  direct  pressure  renewed. 

In  some  old  cases  excision  of  the  head  has  improved  function. 


Fig.  426. 


2.  Dislocation  of  the  Radius  Outward.^ 

Excluding  the  cases  in  which  tlie  dislocation  is  accompanied  by  frac- 
ture of  the  ulna  in  its  upper  portion  and  those  in  which  the  displace- 
ment outward  is  comparatively  slight  and  is  associated  with  a  more 

important  displacement  backward  or 
forward,  the  recorded  instances  of  this 
injury  are  very  few,  and  in  some  of 
these,  even,  the  description  justifies  a 
doubt  whether  they  should  not  rather 
be  placed  in  one  of  the  two  other  classes. 
In  Nelaton's  case  the  dislocation  oc- 
curred in  childhood  and  had  existed 
for  twenty  years ;  the  position  of  the 
radius  is  shown  in  Fig.  426.  Flexion 
and  extension  were  preserved  ;  supina- 
tion was  impossible. 

Wagner  reported  to  the  Germau  Sur- 
gical Congress,  in  1886,  three  cases  of 
dislocation  outward  complicated  by 
fracture  of  the  inner  portion  of  the 
head  of  the  radius.  In  the  first  two 
cases  the  injury  was  caused  by  press- 
ure against  the  back  of  the  flexed 
elbow  while  the  palm  of  the  hand 
was  resting  against  a  firm  object  in 
front.  Thus,  a  lad,  eighteen  years 
old,  pushing  a  coal-wagon  on  a  tram- 
way with  his  forearm  pronated  and 
flexed,  was  struck  on  the  elbow  by  an- 
other wagon  coming  up  from  behind. 
A  year  had  elapsed  since  the  accident 
when  the  first  case  was  seen,  during 
which  the  joint  had  been  steadily  grow- 
The  elbow  was  flexed  at  a  right  angle ;  flexion,  extension. 


Dislocation  of  the  head  of  the  radius 
outward ;  the  trochlea  is  much  broad- 
ened.   (Nelaton.) 


ing  stiifer. 


1  For  bibliography  see :  Nelaton,  Path.  Chir.,  vol.  ii.  p.  400;  Gerdy,  Arcb.  gen.  de  Med., 
183.5,  vol.  vii.  p.  161;  Parker,  New  York  Journal  of  Medicine,  1852,  p.  189;  Pitba  and 
Billroth,  Chirurgie,  vol.  iv.  Part  II.  B.  p.  92  ;  Pingaud.  Diet.  Encyclop.  des  Sc.  Med.,  art. 
Coude;  Wagner,  Beilage  zum  Centbl.  fiir  Chir.,  1886,  No.  24,  p.  93;  Lobker,  ibid.,  p.  92; 
Bartels,  Arch,  fiir  klin.  Chir.,  1874,  vol.  xvi.  p.  643  ;  Schroter,  ibid.,  vol.  xlvi.  p.  4.  Thonias- 
sin's  and  Chedieu's  cases,  quoted  by  Malgaigne,  seem  to  belong  among  the  anterior  dislo- 
cations. 


DISLOCATIONS  OF  THE  RADIUS  ALONE.  741 

and  rotation  were  almost  entirely  lost.  On  the  outer  side  of  the  exter- 
nal condyle  was  a  large  bony  prominence,  the  thickened  and  immovable 
head  of  the  radius ;  there  were  no  abnormalities  in  the  other  parts  of 
the  joint,  and  no  sign  of  a  fracture  of  the  ulna.  The  head  of  the  radius 
was  excised ;  it  was  found  thickly  enveloped  in  fibrous  tissue,  to  which 
the  appearance  of  thickening  was  due,  and  had  lost  from  its  iimer  side 
a  flat,  wedge-shaped  piece  constituting  about  one-sixth  of  its  diameter. 
The  fragment  was  found  adherent  to  the  capsule  and  was  also  removed. 
Recovery  took  place  without  accident,  and  the  mobility  of  the  joint 
steadily  increased  for  some  time.  At  the  time  of  the  report,  nine  years 
later,  flexion  could  be  made  to  an  angle  of  80  degrees,  extension  to  150 
degrees,  pronation  was  almost  normal,  supination  somewhat  restricted. 

In  the  second  case,  a  man,  twenty-six  years  old,  was  injured  in  the 
same  manner,  and  was  seen  while  the  injury  Mas  fresh.  Reduction 
was  effected,  after  several  unsuccessful  attempts,  by,  first,  adduction  of 
the  flexed  limb,  then  by  the  utmost  possible  abduction,  with  supina- 
tion, of  the  completely  extended  limb,  combined  with  pressure  upon 
the  head  of  the  radius.  When  the  dressings  were  removed,  a  month 
later,  passive  movements  were  very  painful  and  limited,  and,  as  no 
improvement  followed,  excision  was  done  five  months  after  the  accident. 
The  head  of  the  radius  was  found  thickened  and  absolutely  fixed,  and 
the  fragment  reunited  to  it  by  a  loose  fibrous  union;  the  failure  of 
union  was  attributed  to  the  interposition  of  a  small  piece  of  the  artic- 
ular cartilage.  Recovery  followed  without  accident,  but  the  mobility 
of  the  joint  was  not  increased. 

In  the  third  case  the  patient  had  received  his  injury  twenty-two 
years  before,  when  six  years  old,  by  a  fall  from  a  horse,  "  The  head 
of  the  radius  stood  outside  upon  the  external  condyle,"  and  was  flat- 
tened on  its  inner  side ;  there  was  no  sign  of  any  injury  to  the  ulna. 
The  movements  of  the  joints  were  completely  normal, 

Lobker,  in  a  paper  read  before  the  same  congi'ess,  re])orted  two  cases 
of  the  same  combination  of  dislocation  outward  with  fracture  of  the 
inner  portion  of  the  head  of  the  radius  treated  by  excision.  In  each 
case  the  fragment  had  become  united  to  the  adjoining  parts  by  a  pedicle. 
Of  the  26  cases  collected  by  Schrotter  3  were  complicated  with  frac- 
ture of  the  head  of  the  radius  and  13  with  that  of  the  ulna. 

Bartels  reported  a  unique  case  in  which  the  heads  of  both  radii  had 
gradually  become  displaced  outward.  The  patient  was  a  man  forty- 
three  years  old,  who,  while  lying  in  lios}>ital  with  a  broken  leg,  called 
the  surgeon's  attention  to  his  elbows.  He  said  that  the  deformity 
dated  from  his  eleventh  year;  his  father  had  at  that  time  put  him  at 
hard  work,  usually  pushing  a  loaded  cart;  pain  Mas  soon  felt  in  the 
elboM's,  and  increased  steadily,  but  he  Mas  kept  at  work.  The  liead  of 
the  radius  rested  on  the  outer  side  of  the  external  condyle  Mhcn  the 
limb  Mas  fully  extended  and  supinatcd  ;  mIicu  extended  and  })ronated, 
the  head  was  less  prominent,  and  rested  partly  on  the  outer  part  of  the 
articidar  surface  of  the  capitellinn,  and  Mhen  flexed  and  ])ronatcd  the 
head   returned  to  its  place. 

Barros  could  produce  the  dislocation  exiwrimcntally  in  only  one  May, 
by  pressure  against  the  ball  of  the  hand,  and  simultaneous  fi»rcible 
51 


742  DISLOCATIONS. 

adduction  of  the  forearm,  by  which  the  external  lateral  ligament  was 
torn. 

The  general  symptoms  in  the  recent  cases  showed  no  special  or  char- 
acteristic features ;  the  limb  appears  to  have  been  partly  flexed  and 
pronated,  and  the  movements  of  the  joint  restricted.  In  the  older 
cases,  the  normal  movements  were  more  or  less  completely  re-estab- 
lished. 

The  diagnosis  is  made  by  recognition  of  the  presence  of  the  head  of 
the  radius  on  the  outer  side  of  the  condyle.  Reduction,  except  when 
there  is  fracture  of  the  head  or  inter})osition  of  the  torn  orbicular  liga- 
ment, should  be  easy  by  adduction  of  the  forearm  and  direct  pressure 
on  the  head  of  the  radius. 

3.  Dislocations  Forward. 

These  are  the  most  common  of  the  three  varieties,  even  excluding 
from  them  the  not  unusual  subluxation  which  occurs  in  children,  and 
will  be  described  in  the  next  section,  and  those  cases  which  are  com- 
plicated by  fracture  of  the  ulna  {vide  infra).  The  dislocation  is  char- 
acterized by  the  position  of  the  head  of  the  radius  in  front  of  its 
normal  position  when  the  forearm  is  extended,  and  above  it  when  the 
forearm  is  flexed  at  a  right  angle.  Several  authors  describe  two  forms, 
the  complete  and  the  incomplete,  including  in  the  latter  those  cases  in 
which  in  flexion  at  a  right  angle  the  head  of  the  radius  has  not  entirely 
left  the  articular  surface  of  the  capitellum,  but  remains  in  contact  with 
its  upper  portion.  The  distinction  between  complete  and  incomplete  is 
an  arbitrary  one  and  does  not  seem  to  deserve  to  be  retained,  for  even 
in  the  former  the  head  of  the  radius  sometimes  descends  upon  the 
articular  surface  of  the  capitellum  when  the  limb  is  extended. 

The  causes  mentioned  in  the  reported  cases  include  falls  upon  the 
hand  or  upon  the  elbow,  and  traction  upon  the  forearm.  In  experi- 
ments upon  the  cadaver  the  dislocation  has  been  produced  by  forced 
pronation,  in  which,  according  to  Filugelli,  quoted  by  Streubel,  a  ful- 
crum is  established  by  contact  between  the  radius  and  ulna  in  their 
upper  third  at  the  point  at  which  they  cross,  the  effect  of  which  is  to 
cause  the  head  of  the  radius  to  move  forward  and  inward,  with  rupture 
of  the  anterior  portion  of  the  annular  ligament  when  the  pronation  is 
exaggerated. 

As  in  the  two  preceding  varieties,  the  mode  of  production  is  far  from 
clear.  That  the  head  should  be  displaced  by  direct  violence  is  not 
difficult  to  comprehend,  but  the  cases  in  which  this  mode  of  production 
can  be  invoked  are  few.  Traction  upon  the  forearm,  combined  prob- 
ably with  exaggerated  pronation,  must  also,  I  think,  be  admitted  as  an 
occasional  cause,  especially  in  children,  both  because  of  its  efficiency 
to  produce  the  dislocation  upon  the  cadaver,  and  because  the  histories 
of  one  or  two  cases  in  adults  are  not  open  to  any  other  explanation, 
as  in  Boyer's  case  of  the  footman  Avho  slipped  while  getting  up  behind 
a  carriage,  and  remained  suspended  by  his  hands.  It  seems  probable 
that  some  of  the  cases  in  which  the  injury  was  received  in  childhood, 
and  remained  unreduced,  may  have  been  dislocations  by  elongatioUj  and 


DISLOCATIONS  OF  THE  RADIUS  ALONE.  743 

tliat  the  head  remained  fixed  in  its  new  position,  or  perhaps  was  still 
further  displaced  by  use.  In  a  fall  upon  the  hand,  it  seems  probable 
that  the  dislocation  could  be  produced  only  by  hyperextension  and 
pressure  upon  the  lower  end  of  the  radius,  aided  by  supination  or  pro- 
nation, and  this  opinion  is  confirmed  by  experiment.  A  case  of  Mal- 
gaigne's^  seems  to  support  this  theory,  for  at  the  patient's  death,  seven 
weeks  after  the  accident,  the  posterior  fourth  of  the  head  of  the  radius 
was  found  to  have  been  broken  off.  In  two  of  Lobker's  "^  cases  a 
piece  was  broken  from  the  outer  portion  of  the  head,  which  suggests, 
what  is  probable  also  on  other  grounds,  that  abduction  of  the  forearm 
may  also  be  a  factor. 

In  a  case  reported  by  Ross^  the  dislocation  occurred  during  an  epi- 
leptic convulsion  and  was  attributed  to  muscular  action,  the  unopposed 
contraction  of  the  biceps  and  pronator  radii  teres. 

Pathology.  No  autopsies  have  been  reported  in  recent  cases.  In 
experiments  upon  the  cadaver  (Streubel,  Pingaud)  the  capsule  has  been 
found  torn  transversely  in  front  close  to  its  attachment  to  the  humerus 
(Fig.  427),  and  the  annular  ligament  untorn  and  encircling  only  the 
neck  of  the  radius  while  the  head  projected  forward  through  the  rent 
in  the  capsule  and  rested,  by  its  posterior  edge  only,  against  the  artic- 
ular surface  of  the  capitellum. 

Fig.  427. 


Hilton's  case  of  dislocation  of  tlie  head  of  the  radius   forward. 

In  a  number  of  cases,  ten  or  twelve,  the  opportunity  has  arisen  to 
examine  old  dislocations.  Malgaigne  has  described  his  own,  quoted 
above,  in  which  the  posterior  fourth  of  the  head  of  the  radius  was 
broken  off  and  the  capsule  was  intact,  and  two  specimens  in  the  Musee 
Dupuytren  (cases  of  Desault  and  Prestat).  Cooper*  describes  and  fig- 
ures a  specimen  preserved  at  St.  Tliomas's  Hospital ;  the  others  are 
those  of  Danyau,^  Debruyn,"  two  cases,  Hilton,''  Trelat,*  Krouloin,'^  a 
specimen  in  the  museum  at  Zurich,  and  Lobker,  the  two  cases  above 
referred  to  ;  see  also  Schr5tter.''^ 

In  Malgaigne's,  Danyau's,  one  of  Debruyn's,  Trelat's,  and  the  two 
specimens  of  the  Musee  Dupuytren  the  annular  ligament  was  stretched 

1  Malgaigne  :  Loc.  cit.,  p.  Hoi . 

«  Lobker:  Beilage  zum  Centralblatt  fiir  Chir.,  188G.  No.  21.  p.  92. 

3  Streubel :   Loc.  cit.,  p.  75.  *  Cooper  :  Loc.  cit..  p._392. 

^  Danyau  :  Annales  de  la  Cliir.  Frangaise  ct  Etrangcre.  1841,  vol.  ii.  p.  72. 

G  Dfhruyn:   ll)id.,  1843,  vol.  ix.  ]..  88. 

7  Hilton:   Uuv'.s  Hospital  Hcports    1817,  vol.  V.  p.  93. 

8  Trelat :   Bul'l.  de  la  Sciciete  Anatoniiiiue,  ISoS,  p.  487. 
"  Kronlein :   Di'iilsclie  Cliiriirgie,  Lief.  2(i,  p.  44. 

1"  Schrotter :  Arcli.  fiir  klin.  Chir.,  vol.  xlvi. 


744 


DISLOCATIONS. 


but  not  torn ;  in  Hilton's  its  upper  portion  was  torn,  but  the  more 
external  and  superficial  fibres  remained  intact  and  were  closely  wrapped 
about  the  neck  of  the  radius ;  in  Cooper's  the  annular,  oblique,  fore- 
part of  the  capsular,  and  a  portion  of  the  interosseous  ligament  were 
torn  through.  With  reference  to  some  of  these  cases  the  question  has 
been  raised  whether  the  annular  ligament  found  at  the  autopsy  was 
not  one  of  new  formation. 

The  head  of  the  radius  rests,  in  partial  flexion,  upon  the  anterior 
surface  of  the  external  condyle  above  and  usually  somewhat  to  the 
inner  side  of  its  normal  position,  and  either  in  contact  with  the  coro- 
noid  process  or  (Hilton)  separated  from  it  by  the  interposed  tendon  of 
the  brachialis  anticus.     In  some  cases  a  piece  has  been  broken  from 

Fig.  428. 


Dislocation  of  upper  end  of  radius. 

its  posterior  or  outer  border.  In  several  of  the  cases  a  hollow  had 
formed  for  its  reception  on  the  anterior  surface  of  the  humerus  ;  the 
new  articulation  was  either  entirely  above  the  old  one,  or  included  the 
upper  part  of  the  capitellum,  or  (Trelat)  extended  over  the  outer  por- 
tion of  the  front  of  the  trochlea.  The  head  of  the  radius  was  deformed 
and  had  suffered  the  loss  of  more  or  less  of  its  cartilage  of  incrustation  ; 
in  some  cases  it  was  enlarged,  in  others  diminished  in  size.  In  Kron- 
lein's  specimen  an  extensive  outgrowth  of  bone  had  formed  upon  the 
inner  side,  giving  the  upper  end  of  the  bone  an  appearance  similar  to 
that  of  the  upper  end  of  the  femur,  and  articulating  with  a  new  cavity 
upon  the  humerus  ;  it  is  stated  that  the  movements  of  rotation  had  been 
completely  restored. 

An  interesting  feature  in  Hilton's  case  was  that  the  radius  had  been 


DISLOCATIONS  OF  THE  RADIUS  ALONE.  745 

displaced  bodily  upward  along  the  ulna,  and  this  displacement  had  pro- 
duced changes  at  the  wrist. 

Malgaigne  observed  and  called  especial  attention  to  abduction  of  the 
forearm,  which  does  not  appear  to  have  been  observed  by  others.  It 
furnishes  a  satisfactory  explanation  of  the  displacement  of  the  radius 
upward  as  well  as  forward,  which  could  not  otherwise  be  accounted  for 
except  by  such  a  change  in  the  level  of  the  bones  at  the  wrist  as  was 
noted  in  Hilton's  case.  Abduction  of  the  forearm  might  easily  be 
overlooked  while  the  joint  is  partly  flexed  unless  comparative  measure- 
ments are  made. 

Symptoms.  The  elbow  is  slightly  flexed  and  the  forearm  almost 
always  more  or  less  pronated ;  in  a  few  cases  supination  has  been  ])res- 
ent.  Voluntary  and  communicated  movements  are  painful,  and  of  the 
latter  flexion  nearly  to  a  right  angle  and  almost  complete  extension  are 
possible,  pronation  is  usually  complete,  but  supination  much  restricted. 
Abduction  of  the  forearm  has  been  noted,  possibly  it  is  quite  common, 
and  when  present  it  can  be  demonstrated  by  comparative  measurements 
of  the  radial  borders  of  the  two  forearms,  the  injured  one  being  short- 
ened. The  region  of  the  elbow  is  swollen  in  front  and  on  the  outer 
side ;  the  absence  of  the  head  of  the  radius  from  its  normal  position  is 
shown  by  the  depressibility  of  the  soft  parts  on  the  outer  side  of  the 
joint  below  the  condyle,  and  its  presence  in  the  fold  of  the  elbow  can 
generally  be  recognized  by  the  finger ;  sometimes  it  is  so  prominent 
there  that  it  appears  to  be  subcutaneous,  and  the  saucer-like  depression 
of  its  upper  surface  can  be  traced  when  the  joint  is  extended.  Flexion 
of  the  forearm  is  abruptly  arrested  at  or  near  a  right  angle  by  the 
impact  of  the  head  of  the  radius  upon  the  front  of  the  humerus. 

In  the  older  cases  the  restoration  of  function  may  be  almost  com- 
plete, the  range  of  motion  being  limited  only  in  extreme  flexion  and 
supination. 

In  Hilton's  case  the  associated  changes  at  the  wrist  caused  a  corre- 
sponding deformity  there,  abduction  of  the  hand  ;  and  it  seems  not 
unlikely  that  even  in  some  recent  cases  the  wrist  may  be  painful  or 
distorted. 

Treatment.  Reduction  has  been  easy  in  some  recent  cases,  and  diffi- 
cult or  impossible  in  others.  The  measures  which  liave  been  most 
successful  are  traction  upon  the  radius  at  the  wrist,  the  forearm  being 
supinated  and  extended,  combined  with  pressure  upon  the  head  of  the 
radius.  Malgaigne  suggests,  very  properly,  that  adduction  of  the  fore- 
arm would  be  more  likely  than  traction  to  overcome  the  overriding  of 
the  radius.  Hilton  reduced  the  displacement  in  his  sj)ecimen,  wiiich 
had  existed  for  many  years,  by  placing  a  small  wedge  between  the 
upper  surface  of  the  radius  and  the  humerus,  and  then  flexing  the  fore- 
arm by  pressing  upon  the  lower  end  of  the  ulna ;  when  flexion  was 
nearly  complete  direct  pressure  upon  the  head  of  the  radius  forced  it 
backward  into  place.  The  eifect  of  this  device  was  to  disphice  the 
radius  downward  along  the  ulna  to  a  distance  e<iual  to  the  thickness  of 
the  wedge,  and  to  rupture  the  ligaments  which  bound  the  two  bones 
together.  A  marked  tendency  to  recurrence  has  been  frequently 
noticed,  and  has  generally  been  attributed  to  interposition  of  a  portion 


746  DISLOCATIONS. 

of  the  capsule.  I  am  inclined  to  think  it  due,  in  some  cases  at  least, 
to  the  persistence  of  this  bodily  displacement  of  the  radius  upward. 
If  so,  the  condition  would  be  shown,  after  reduction,  by  loss  of  the 
outward  inclination  of  the  forearm  in  full  extension,  and  the  effort 
should  be  made  to  overcome  it  by  restoring  this  angle  by  forcible 
abduction. 

The  position  of  the  rent  in  the  anterior  portion  of  the  capsule  sug- 
gests that  after  reduction  the  joint  should  be  kept  flexed,  and  although 
recurrence  of  the  dislocation  has  taken  place  with  the  limb  in  this 
position,  it  does  not  seem  so  likely  to  favor  such  recurrence  as  the 
extended  position. 

4.  Dislocation  by  Elongation,  or  the  Subluxation  of  Young 

Children.^ 

Under  these  names  is  described  an  injury  which  is  very  frequently 
observed,  but  the  nature  of  which,  after  nearly  two  centuries  of  dis- 
cussion, is  still  in  dispute.  Its  features  are  well  marked  ;  a  young 
child,  generally  less  than  three  years  old,  is  lifted  or  pulled  by  the 
hand ;  it  cries  out  with  pain,  and  refuses  to  use  the  limb,  which  hangs 
motionless  by  the  side,  somewhat  flexed  at  the  elbow,  and  more  or  less 
pronated.  A  careful  examination  fails  to  discover  marked  changes  in 
the  anatomical  relations  of  the  bones  at  the  elbow  or  wrist ;  passive 
motion  at  both  joints  is  free,  but  painful,  except  supination,  which  is 
resisted ;  often  during  the  manipulations  made  in  the  examination,  or 
on  forced  supination,  a  slight  click  is  heard,  and  the  child  at  once  is 
able  to  use  the  limb  freely  without  pain. 

As  early  as  1671  Fournier  described  the  injury  as  an  incomplete 
dislocation  charactei-ized  by  relaxation  of  the  ligaments  and  elongation 
of  the  radius,  meaning  by  the  latter  direct  separation  downward  or 
diastasis.  Nearly  a  hundred  years  later,  Duverney  gave  a  clear  and 
exact  description  of  it  as  an  injury  occurring  frequently  in  children  ; 
he  attributed  it  to  forcible  traction  at  the  wrist,  and  gave  as  its  chief 
symptom  the  opposition  to  supination  of  the  forearm,  and  as  the  treat- 
ment forcible  supination  with  pressure  from  before  backward  upon  the 
head  of  the  radius  followed  by  flexion  of  the  elbow.  He  thought  the 
injury  was  not  merely  an  elongation  of  the  radius,  but  also  the  escape 
of  its  head  below  tlie  edge  of  the  orbicular  ligament.  Nearly  a  cen- 
tury and  a  half  has  passed  since  the  publication  of  his  views,  and  but 
little  has  been  added  to  his  description  of  the  etiology,  symptoms,  or 
treatment,  and  while  the  years  have  brought  many  other  theories  con- 
cerning the  pathology  his  is  the  one  that  is  now  most  widely  held. 

^  The  papers  upon  this  subject  are  numerous;  the  following  bibliography  contains  the 
more  important:  Gardner,  London  Medical  Gazette,  1837,  vol.  xx.  p.  878;  Hodges,  Boston 
Medical  and  Surgical  .Journal.  1862,  vol.  Ixvii.  p.  129  ;  Goyrand,  Gazette  medicale  de 
Paris,  1837,  p.  n."".,  and  Bull.de  la  Societe  de  Chirurgie,  1861,  p.  605;  Pingaud,  Diet. 
Encyclopcdi(ine,  art.  CuikIc,  p.  580;  Hamilton,  New  York  Medical  Journal,  Jan.  3,  1885, 
p.  8 ;  Duverney,  Mabid  ics  dos  Os,  1751 ;  Bouley,  De  radii  superioris  extremitatis  dimotione, 
in  infantibu.s  fre(iuent'ori,  1787;  Rendu,  Gazette  medicale,  1841,  p.  301  ;  Perrin.  Journal 
de  Chirurfrie  de  Malgaigne,  vol.  v.  p.  145;  Streubel,  Prager  Vierteljahrschrift,  1850,  vol. 
ii.  p.  90;  Van  Ar.sdale,  Annals  of  Surgery,  June,  1889  ;  A.  Broca,  La  pronation  douloureuse 
des.jeunes  enfants,  Gaz.  des  Hop.,  1903,  No.  56. 


DISLOCATIONS  OF  THE  RADIUS  ALONE.  747 

In  1787  Bottentiiit  presided  at  the  presentation,  and,  according  to 
Malgaigne,  was  probably  the  real  author,  of  a  thesis  by  "Bouley  before 
the  Ecoles  de  Cliirurgie,  in  which  tlie  theory  of  the  agency  of  forced 
pronation  in  the  production  of  the  injury  was  advanced;  it  was  argued 
that  in  this  movement  the  radius  and  ulna  came  into  contact  at  the 
point  where  they  crossed  each  other  near  the  elbow,  and  that,  the 
movement  being  continued,  the  head  of  the  radius  was  displaced  for- 
ward or  outward. 

At  the  beginning  of  the  present  century  Martin,  in  France,  1809, 
and  Monteggia,  in  Italy,  1814,  descril)ed  the  injury  and  reported  cases, 
but  the  former,  unfortunately,  appears  to  have  encountered  also  some 
dislocations  backward,  and  he  not  only  included  them  in  the  same 
group,  but  he  also  thought  that  the  radius  was  dislocated  backward  in 
all,  and  this  opinion  has  survived  in  a  measure  nntil  the  present  time, 
and  has  led  systematic  writers  to  describe  a  dislocation  backward  as 
one  of  the  forms,  although  it  does  not  appear  that  there  is  any  other 
authority  for  the  statement  than  Martin. 

As  the  injury  is  one  that  seems  but  rarely  to  fall  under  the  observa- 
tion of  the  general  surgeon,  probably  because  of  the  facility  with 
which  it  is  reduced,  the  authors  of  the  surgical  text-books  either  made 
no  mention  of  it  or  followed  in  their  brief  descriptions  the  account 
given  by  Martin,  or  by  those  who  had  copied  from  him.     But  between 

1836  and  1850  several  cases  were  published  in  England  and  in  France, 
and  new  theories  concerning  its  nature   were  advanced.     Gardner  in 

1837  and  Rendu  in  1841  attributed  the  fixation  to  the  locking  of  the 
bicipital  tuberosity  behind  the  ulna,  but  the  latter,  who  in  two  cases 
had  made  the  important  observation  that  the  wrist  also  was  swollen 
and  tender,  added  to  this  supposed  locking  of  the  tuberosity,  which  he 
regarded  as  probably  exceptional,  a  rupture  of  the  ligaments  of  the 
wrist.  Perrin,  in  1849,  thought  the  head  of  the  radius  was  caught 
below  the  lower  edge  of  the  lesser  sigmoid  cavity,  and  Goyrand,  who 
saw  a  large  number  of  cases,  thought  the  lesion  was  an  incomplete 
dislocation,  in  which  the  displacement  was  so  slight  as  to  cause  no 
recognizable  deformity  at  the  elbow.  Malgaigne,  1854,  included  it 
among  the  incomplete  dislocations  forward,  and  others  did  likewise. 

In  1850  Streubel  made  the  theory  of  incomplete  luxation  more 
definite,  by  showing  that  if  the  forearm  of  the  cadaver  of  a  young 
child  was  forcibly  pronated,  the  head  of  the  radius  moved  forward, 
and  the  posterior  portion  of  the  capsule  was  forced  in  by  atmospheric 
pressure  between  the  radius  and  the  capitellum,  and  that  if  then  the 
pronation  was  diminished,  the  slight  displacement  of  the  radius  and 
the  interposition  of  the  capsule  would  persist  even  while  gentle  move- 
ments of  the  joint  were  made ;  but  that  under  sudden  extension  and 
supination  the  normal  relations  would  be  established.  In  like  manner, 
forced  supination  would  displace  the  radius  backward,  and  lead  to 
interposition  of  the  anterior  portion  of  the  capsule.  In  the  bodies  of 
adults  neither  manipulation  would  produce  tills  result. 

In  1856  Chassaignac '  described,  under  tlie  title  "jxtrali/sic  doulun- 

>  Chassaignac  :  Archives  cciieralcs  de  Med.,  1856,  vol.  i.  p.  053. 


748 


DISLOCATIONS. 


reuse  des  jeunes  enfants,"  a  number  of  cases  of  the  injury  under  dis- 
cussion, together  with  others  of  a  diiferent  nature,  and  attributed  the 
symptoms  in  all  to  injury  of  the  nerves  of  the  limb.  Finally,  in 
1861,  Goyrand^  returned  to  the  subject  in  a  lengthy  paper,  in  which 
he  abandoned  his  previous  view  and  advanced  the  last  new  theory, 
that  the  lesion  was  situated  not  at  the  elbow,  but  exclusively  at  the 
wrist,  and  consisted  in  a  dislocation  of  the  triangular  fibro-cartilage  in 
front  of  the  lower  end  of  the  ulna.  His  experiments  showed  that  in 
complete  pronation  the  fibro-cartilage  was  carried  so  far  forward  as 
almost  entirely  to  uncover  the  end  of  the  ulna,  and  that  in  forced  pro- 
nation the  uncovering  became  complete.  In  reply  to  a  question  asked 
by  Velpeau,  he  admitted  that  the  displacement  did  not  persist  upon 
the  cadaver  unless  the  hand  was  held  upward  and  supinated,  but  he 
thought  that  the  tonic  contraction  of  the  muscles  in  the  living  would 
maintain  it.  He  did  not  explain  why  such  a  lesion  should  be  more 
easily  produced  in  a  child  than  in  an  adult. 

It  may  be  worth  while  to  add  that  the  editor  of  the  Medko-CMrur- 
gical  Review,  in  1839,  thought  the  injury  was  a  separation  of  the 
upper  epiphysis  of  the  radius,  and  Fougeu,  in  1861,  a  separation  of 
the  lower  one. 

Pingaud,^  in  his  experiments  upon  the  cadaver,  found,  as  Goyrand 
had  similarly  done  in  1837,  that  the  head  of  the  radius  could  be 
drawn  out  through  the  orbicular  ligament  by  forcible  adduction  of  the 
forearm,  so  far  that  its  anterior  edge  would  engage  below  the  lower 
border  of  the  ligament  (Fig.  429),  and  the  bones  would  remain  sepa- 

FiG.  429. 


Subluxation  of  the  head  of  the  radius.    (Pingaud.) 


rated  by  a  distance  of  about  a  quarter  of  an  inch,  but  without  dis- 
])lacement  of  the  radius  forward,  backward,  or  outward,  unless  forced 
pronation  was  added  to  the  adduction,  in  which  case  the  head  moved 
forward  ;  and  as  this  condition  of  the  parts  coincided  with  a  limitation 
of  the  freedom  of  rotation  of  the  forearm  similar  to  that  observed 
clinically  in  the  cases  in  question,  and  as  the  normal  relations  of  the 
parts  were  restored  by  the  same  manoeuvres  which  relieved  the  little 
patients,   he   reached   the   conclusion  that   the   nature   of  the  lesion 

'  Goyrand :  Bull,  de  la  Socicte  de  Chir.,  1861,  p.  596. 
*  Pingaud :  Loc.  cit.,  1878. 


DISLOCATIONS  OF   THE  RADIUS  ALONE.  749 

observed  clinically  was  the  same  as  that  which  he  had  produced 
experimentally,  and  that  the  clinical  injury  was,  therefore,  a  disloca- 
tion of  the  radius  downward  below  the  annular  lio;ainent,  or,  in  other 
words,  that  Duverney's  theory  was  the  correct  one.  He  showed  fur- 
ther, that  the  younger  the  child  the  more  easily  could  this  displace- 
ment be  effected,  and  the  more  complete,  circularly,  would  it  be.  He 
would  not  assert  that  this  was  the  only  cause  of  the  clinical  condition, 
but  contented  himself  with  proving-  that  it  was  at  least  one  ;  his  reserve 
being  apparently  due  to  the  inapplicability  of  the  ex})lanation  to  the 
reported  cases  in  which  the  radius  was  said  to  have  been  displaced 
backward,  cases  which  we  have  seen  to  rest  only  upon  Martin's  asser- 
tion. His  experiments  have  been  repeated,  and  his  results  verified  by 
others;  Poinsot  accepts  his  explanation  fully  for  the  usual  cases,  and 
Streubel's  for  those  of  displacement  backward.  Stone^  calls  attention 
to  the  fact  that  the  head  of  the  radius  is  not  an  exact  circle  and  that 
when  the  dislocation  is  effected  by  traction  in  pronation  "  supination  is 
resisted  because  the  tense  lateral  ligament  forces  the  flattened  side  of 
the  radial  head  against  the  anterior  edge  of  the  lesser  sigmoid  articula- 
tion and  the  inner  attachment  of  the  annular  ligament."  The  pressure 
was  sufficient  to  make  a  groove  on  the  side  of  the  head. 

Turning  now  to  the  clinical  evidence,  for  there  have  been  no  post- 
mortem examinations,  it  appears  that  the  injury  is  common  in  young 
children  between  the  ages  of  one  and  three  years,  and  is  rarely  seen 
after  the  age  of  six  years,  and  not  infrequently  recurs.  Goyraud  (loc. 
cit.,  1861)  had  seen  at  least  two  hundred  cases  in  thirty  years,  and 
quotes  Chabrely  {Journal  de  Medecine  de  Bordeaux,  October,  1860, 
p.  481)  as  saying  that  hardly  a  month  passed,  he  might  say  hardly  a 
week,  in  which  he  was  not  called  to  a  case,  and  Fougeu  as  having  seen 
thirty-five  cases  ;  in  the  discussion  that  followed  the  reading  of  Goy- 
rand's  paper,  Marjolin  stated  that  he  had  seen  about  sixty  cases. 
Snedden^  saw  ten  cases  in  ten  years  in  private  practice  ;  and  Linde- 
man^  saw  twenty-four  cases  and  Van  Arsdale  one  hundred  in  two  years 
in  dispensary  practice.  The  cause  is  traction  upon  the  arm  at  the  hand 
or  wrist,  as  in  lifting  a  child,  or  in  holding  it  when  it  stumbles,  and  in 
two  cases  in  drawing  the  arm  through  the  sleeve  of  the  dress.  It 
seems  to  me  that  exaggerated  pronation  does  not  enter  into  the  mechan- 
ism by  which  the  lesion  is  produced,  but  that  the  violence  is  simply 
traction  exerted  upon  the  extended  elbow,  possibly  combined  with 
adduction,  for  traction  would  tend  to  make  the  limb  exactly  straight, 
and  thus  overcome  the  normal  inclination  of  the  forearm  outward  ;  or 
the  grasp  upon  the  forearm  may  be  so  firm  that  an  actual  inward  incli- 
nation would  be  produced  in  case  the  effort  was  not  a  simple  traction, 
but  was  combined  with  a  movement  that  tended  to  swing  the  child 
upward  along  a  curve  whose  centre  was  its  wrist  and  whose  radius 
was  its  extended  arm.  At  least,  in  lifting  a  living  child  by  llie 
arm  I  have  not  been  able  to  make  exaggerated  pronation,  for  rota- 

1  Stone:  Journ.  Am.  Mod.  Ass.,  .July,  1010,  p.  28. 

2  Sneddon :  British  Medical  .Ir)urn:il,  1SS2,  vol.  i,  p.  499. 
sLindeman:  British  Medical  Journal,  1885,  vol.  ii,  p.  1058. 


750  DISLOCATIONS. 

tion  at  the  shoulder  is  so  free  that  the  Hmit  of  pronation  is  not  easily 
reached,  and  this  is  unquestionably  true  when  the  child  is  lifted  by 
both  hands. 

The  child  at  once  cries  out  in  pain  and  refuses  to  use  the  limb,  which 
hangs  motionless  by  its  side,  or  is  supported,  with  the  elbow  slightly 
flexed,  across  the  front  of  the  abdomen;  the  wrist  is  completely  or 
partly  pronated.  Examination  shows  sensitiveness  at  the  outer  por- 
tion of  the  elbow,  in  some  cases  also  at  the  back  of  the  wrist,  and  in 
others  exclusively  at  the  wrist,  with  swelling  after  the  lapse  of  from 
thirty  to  thirty-six  hours.  The  head  of  the  radius  is  sometimes 
slightly  but  distinctly  displaced  forward,  but  in  most  cases  no  other 
change  than  a  slight  longitudinal  separation  between  the  radius  and 
the  capitellum  is  recognizable.  There  is  pain  on  pressure  over  the 
head  of  the  radius. 

Although  the  child  does  not  voluntarily  move  the  joint,  it  can  be 
freely  moved  by  the  surgeon  in  every  direction  except  supination,  and 
will  sometimes  be  held  by  the  child  in  such  a  position  as  may  be  given 
to  it.  In  only  one  recorded  case,  Duges,^  was  the  limb  in  supination  ; 
with  that  exception  the  constant  and  pathognomonic  symptom  is  the 
interference  with  supination. 

These  facts,  taken  in  connection  with  the  results  of  experiment,  indi- 
cate that  Duverney's  opinion  was  correct  and  that  the  injury  consists 
in  the  escape  of  the  front  portion  of  the  head  of  the  radius  below  the 
orbicular  ligament,  and  that  it  is  produced  by  traction  and  adduction 
of  the  extended  forearm.  Gov  rand's  last  explanation — dislocation  of 
the  triangular  fibro-cartilage  at  the  wrist — cannot  maintain  itself  against 
the  overwhelming  clinical  evidence  of  the  existence  of  a  lesion  at  the 
elbow,  supported,  as  it  is,  by  experiment,  especially  since  it  has  no 
better  foundation  than  the  impression  that  the  click  which  was  heard 
during  reduction  was  produced  at  the  wrist  and  not  at  the  elbow. 
Against  its  correctness  are  the  facts  that  although  exaggerated  prona- 
tion will  effect  such  a  dislocation,  yet  there  is  nothing  to  prove  that 
the  displacement  will  not  immediately  correct  itself  when  the  limb  is 
released,  and  that  there  is  not  only  no  proof  of  the  intervention  of 
exaggerated  pronation  in  clinical  cases,  but  it  was,  furthermore,  cer- 
tainly absent  in  some,  and  probably  in  all.  The  only  difficulty  is  to 
explain  the  well-established  symptoms  of  injury  at  the  back  of  the 
wrist  in  some  of  the  cases.  Possibly  such  cases  may  be  of  a  different 
character  from  the  others,  actual  dislocation  backward  of  the  lower 
end  of  the  ulna  (vide  infra),  and  Goyrand's  explanation  may  be  true 
of  them  ;  or  the  symptoms  may  be  due  to  an  associated  sprain  of  the 
wrist. 

The  experience  of  Chassaignac,  who  treated  his  cases  as  paralytic 
and  saw  them  gradually  recover,  indicates  that  the  lesion  may  be  spon- 
taneously corrected ;  but,  on  the  other  hand,  there  is  reason  to  think 
that  some  of  the  cases  of  forward  dislocation  of  the  head  of  the  radius 
found  in  adults,  which  had  existed  from  childhood,  were  originally  of 
this  kind,  and  that  the  head  had  gradually  become  displaced  farther 

'  Duges:  Journal  hebdomadaire,  1831,  vol.  iv,  p.  196. 


DISLOCATIONS  OF  RADIUS   WITH  FRACTURE  OF   ULNA.      751 

forward.     All  who  have  treated  cases  agree  that  reduction  is  easily 
effected,  usually  by  supination;  some  add  flexion  of  the  elbow. 

DISLOCATION  OF  THE  HEAD  OF  THE  RADIUS  WITH  FRACTURE 

OF  THE  ULNA. 

The  coincidence  of  a  fracture  of  the  shaft  of  the  ulna  with  disloca- 
tion of  the  head  of  the  radius  is  not  infrequent,  and,  since  the  disco^•ery 
of  either  of  the  two  injuries  may  lead  the  surgeon  to  overlook  the 
other,  the  possibility  of  the  coexistence  should  always  be  borne  in  niiiul. 
Malgaigne  attached  so  much  importance  to  this  warning  that  he  formu' 
lated  and  italicized  the  following  two  recommendations  : 

1 .  In  any  fracture  of  the  ulna  alone  look  for  a  dislocation  of  the 
radius. 

2.  In  every  fracture  of  the  forearm  in  which  the  swelling  extends 
above  the  elbow,  remember  that  simple  fracture  is  rarely  accompanied 
by  so  much  swelling,  and  carefully  explore  the  articulation. 

To  complete  the  warning  a  third  precaution  should  be  added,  namely, 
that  in  every  dislocation  of  the  head  of  the  radius  alone,  fracture  of 
the  ulna  should  be  sought  for. 

The  complication  has  received  the  attention  of  most  systematic 
writers  upon  dislocations,  and  has  been  made  the  subject  of  mono- 
graphs by  Malgaigne,^  Greiner,^  and  Dorfler.^  The  latter  collected 
nineteen  cases,  but  the  injury  appears  to  be  of  more  frequent  occur- 
rence than  this  fact  would  indicate,  for  Malgaigne  saw  four  cases,  von 
Pitha  two  or  three,  and  Dorfler  reports  four  cases  from  the  practice  of 
the  surgeon  under  whom  he  was  serving.     I   have  seen  at  least  ten. 

The  cause  in  a  certain  number  of  cases — five  of  Dorfler's  nineteen — 
has  been  direct  violence,  as  the  kick  of  a  horse,  received  upon  the  inner 
or  inner  and  posterior  aspect  of  the  upper  part  of  the  ulna,  first  break- 
ing that  bone  and  then  driving  the  head  of  the  radius  forward  and 
outward  from  its  place  ;  in  others  it  has  been  a  fall  upon  the  arm,  and 
it  is  uncertain  whether  the  ulna  was  broken  by  direct  or  indirect  vio- 
lence. In  Gerdy's  case  the  patient  declared  that  he  fell  upon  his 
extended  hand;  and  in  one  that  came  under  my  care  in  August,  1885, 
the  patient,  a  boy  seven  years  old,  had  fallen  from  a  wagon  and  sus- 
tained a  compound  fracture  of  the  ulna  at  its  middle,  the  wound  in  tiie 
skin  being  in  the  centre  of  the  anterior  aspect  of  the  limb  and  having 
been  produced  from  within  outward  by  the  sharp  end  of  one  of  the 
fragments  ;  the  radius  was  displaced  forward,  upward,  and  inward  so 
far  that  its  concave  upper  surface  could  be  distinctly  felt.  There  was 
no  brLiise  on  the  back  of  the  forearm,  and  I  thought  the  fracture  had 
been  produced  by  indirect  violence,  a  fall    on  the  hand. 

The  only  autopsical  record  I  have  found  is  one  by  Marchand,*  and, 
unfortunately,  it  is  not  entirely  clear.     It  is  stated  that  the  external 

'  Malffaigne:   Revue  medico-chirumifale,  vol.  xiii,  pp.  82  and  90. 

2  Clrenier:  Recherche.s  sur  la  luxation  du  radius  que  complique  la  fracture  du  tiers 
superieur  du  cubitus.     Th("^so  de  Paris,  1.S7S. 

3  Dorfler:  Fractur  dcr  ulna  in  iliieni  ohcron  Dritlol  eombinirt  nut  Luxation  des  Radius; 
Deutsehe  Zeitsc-hrift  fiir  Chir.,  IS.SG,  vol.  xxiii.  p.  :V.iS. 

*  Man-hand:  Bull,  de  la  Societe  Aiiatomique,   1874,  p.  680. 


752  DISLOCATIONS. 

lateral  ligament  was  torn,  the  ulna  was  broken  in  its  upper  third,  and 
the  head  of  the  radius  was  displaced  to  the  outer  side  of  the  epicon- 
dyle;  the  annular  ligament  was  untorn,  but  "no  longer  surrounded 
the  neck  of  the  radius;  it  seemed  rather  to  embrace  the  radial  capsule 
(cupule,  head?),  and  the  radius  seemed  to  have  escaped  below  it." 

Dorfler's  experiments  showed  that  the  parallelism  of  the  radius  and 
the  lower  fragment  of  the  ulna  was  preserved,  with  production  of  an 
angle  in  the  ulna  at  the  point  of  the  fracture;  the  annular  and  anterior 
ligaments  were  torn.  The  limb  was  shortened,  and  crepitus  was  per- 
ceived on  handling;  it.  Clinically,  a  prominent  feature  is  the  marked 
swelling  at  the  elbow,  due  in  part  to  the  displacement  of  the  radius 
and  in  part  to  inflammatory  reaction.  The  displacement  of  the  radius 
is  usually  forward,  sometimes  forward  and  inward,  forward  and  out- 
ward, or  directly  outward. 

Among  the  complications  were  observed  subluxation  of  the  lower 
end  of  the  ulna,  wound  of  the  integument  either  by  the  direct  action 
of  the  causative  violence  or  from  within  outward  by  the  end  of  the 
fragment,  making  the  fracture  compound,  fracture  of  the  epicondyle 
or  external  condyle,  and  more  or  less  paralysis  of  the  extensor  muscles 
of  the  wrist  and  fingers  due  to  stretching  or  rupture  of  the  rausculo- 
spiral  or  posterior  interosseous  nerve. 

The  prognosis  is  good  if  the  displacements  are  promptly  corrected ; 
and  even  if  the  dislocation  of  the  radius  persists  the  restoration  of 
function  may  be  nearly  complete.^ 

On  the  other  hand,  failure  of  union  of  the  fracture  has  been  noted 
(Norris^),  and  persistent  extensor  paralysis  (Dorfler). 

Reduction  in  recent  cases  has  been  easy  ;  the  most  suitable  method 
appears  to  be  traction  upon  the  extended  limb,  followed  by  direct  press- 
ure upon  the  radius  and  then  by  flexion  of  the  elbow.  The  extended 
position  during  traction  is  desirable  in  order  to  avoid  the  interposition 
of  the  torn  anterior  ligament.  After  reduction  the  limb  should  be 
kept  flexed  within  a  right  angle,  and  midway  between  supination  and 
pronation. 

1  Stetten  (Annals  of  Surg.,  Aug.,  1908,  p.  275)  reports  a  case  successfully  treated  by- 
Prof.  Kammerer  and  collects  eight  reported  cases. 

2  Norris:  American  Journal  of  Medical  Sciences,  vol.  xxxi.  p.  20. 


CHAPTER  XLVII. 

DISLOCATIONS  OF  THE  ELBOW.— (Continued.) 

Treatment  of  Old  Dislocations — Congenital  and  Pathological  Dislocations. 

TREATMENT    OF    OLD    DISLOCATIONS. 

The  loss  of  mobility  in  old  dislocations  of  the  elbow,  especially  of 
the  backward  ones,  is  often  so  great  that  the  disability  is  serious  ;  the 
patient  is  unable  to  bring  the  hand  to  the  head  or  chest,  and  is  able  to 
use  it  only  in  the  arc  of  a  circle  who>se  radius  is  nearly  equal  to  the 
length  of  the  extended  limb,  and  he  may,  in  addition,  possess  only  such 
rotation  as  can  be  eifected  by  movements  at  the  shoulder.  Although 
successful  attempts  to  reduce  dislocations  of  several  months'  standing 
were  occasionally  reported,  yet  failure  was  the  rule,  and  the  only  means 
of  alleviating  the  conditions  were  fracture  of  the  olecranon  and  excision 
of  the  joint,  operations  which,  while  they  increased  the  range  of  mo- 
tion, brought  with  them  disadvantages  of  their  own,  such  as  loss  of 
active  extension  and  lack  of  solidity,  which  disinclined  the  surgeon  to 
offer,  and  the  patient  to  accept  them. 

Consideration  of  the  anatomo-pathological  conditions  of  an  old  unre- 
duced backward  dislocation  not  only  fully  explains  the  difficulty  of 
effecting  reduction,  but  even  makes  it  appear  surprising  that  reduction 
should  ever  have  been  satisfactorily  accomplished.  The  overriding  of 
the  bones  along  the  back  of  the  humerus  leads  to  the  formation  of 
new  cicatricial  bonds  between  the  olecranon  and  the  humerus  and  to 
the  establishment  of  new  attachments  by  the  torn  lateral  ligaments  so 
far  above  and  behind  the  centre  of  motion  of  the  old  joint  that  almost 
no  flexion  is  possible  without  their  rupture  or  elongation,  and  the 
return  of  the  bones  to  their  place  can  be  eifected  only  after  a  more 
extensive  rupture  of  these  soft  parts  than  that  which  accompanied  the 
dislocation.  In  attempting  to  rupture  these  bonds  by  forced  flexion 
the  forearm  is  used  as  a  lever  the  fulcrum  of  which  is  situated  on  the 
uhia  below  the  coronoid  process,  and  the  rupturing  strain  is  exerted 
through  the  olecranon  upon  the  ligaments  and  adhesions  connected 
with  it,  and  it  is  not  to.be  wondered  at  tJiat  this  process  should  so 
frequently  have  been  broken  in  the  manipulation  or  the  trochlea  broken 
ofl".  In  addition,  tlie  greater  sigmoid  cavity  ])r(imptly  fills  with  cica- 
tricial tissue,  partly  of  new  formation  and  ])artly  furnished  by  the 
upper  part  of  the  postei"ior  i)ortion  of  the  capsule  which  slips  in  between 
it  and  the  back  of  the  humerus  and  ])ermanently  occupies  the  concavity 
which  should,  after  reduction,  embrace  the  trochlea;  this  pad  of  tissue 
is   found   so   firmly  united  to  the  cartilage   of  the  olecranon   that  its 

(  753  ) 


754 


DISLOCATIONS. 


removal  in  the  reported  arthrotomies  has  required  the  use  of  the  knife. 
The  adhesion  of  tiie  capsule  to  the  articular  surface  of  the  front  of 
the  trochlea  and  the  capitellum  has  not  been  found  to  be  so  close, 
and  the  cartilage  of  their  surfaces  has  been  found,  even  after  the 
lapse  of  several  months,  almost  entirely  unaltered  in  appearance. 
On  the  other  hand,  Dol linger,  in  45  cases,  found  that  degeneration 
and  detachment  of  the  cartilage  on  the  humerus  occurred  within  two 
or  three  months,  and  was  always  more  marked  than  on  the  ulna  and 
radius. 

Furthermore,  the  injury  is  common  in  the  young,  in  whom  the  osteo- 
genic power  of  the  periosteum  is  great  and  in  whom  the  epiphyses  are 
still  growing.  The  effect  of  the  injury,  especially  if  the  periosteum  is 
stripped  up,  is,  therefore,  to  produce  new  formations  of  bone  around 
the  joint  which  contract  adhesions  with  the  other  bones  or  mechanically 
interfere  by  interposition  to  prevent  the  reduction  of  the  dislocation ; 
and,  further,  the  epiphysis  of  the  humerus,  relieved  of  the  pressure 
normally  exerted  upon  it  by  the  radius  and  ulna,  grows  more  rapidly 
and  irregularly,  and  its  articular  surface  may  thus  lose  its  shape  and 
become  unfit  to  receive  the  others  again.  This  deformity  by  exagger- 
ated growth  has  been  especially  noticed  in  the  capitellum  (see  Patholog- 
ical and  Congenital  Didocations),  the  extension  being  downward  and 

forward. 

Fig.  430. 


Old  dislocation  of  elbow.    New  socket  for  head  of  radius.    Bony  union  between  ulua 

and  trochlea. 

These  changes  are  clearly  incompatible  with  successful  reduction  by 
the  means  employed  in  fresh  cases,  even  if  the  force  employed  be  suffi- 
cient to  rupture  the  adhesions  and  bring  the  bones  down  to  the  proper 
level.  It  is  true  that  successes  have  been  occasionally  reported,  but  the 
reports  rarely  go  beyond  the  statement  that  reduction  was  accomplished, 
and  they  leave  the  subsequent  history  of  the  case  and  degree  of  re- 
establishment  of  the  functions  unrecorded.  Until  quite  recently  the 
only  methods  employed  have  been  forcible  attempts  to  reduce  by  trac- 
tion and  the  breaking  of  adhesions,  sometimes  aided  by  subcutaneous 
division  of  the  tendon  of  the  triceps,,  or  of  adhesions  on  the  sides  and 
back  of  the  joint,  increase  of  the  range  of  motion  by  the  same  means 


OLD  DISLOCATIONS  OF  THE  ELBOW.  755 

without  reduction,  reduction  after  fracture  of  the  olecranon  bv  forcible 
flexion,  and  excision  of  the  joint. 

Albert  says  that  Liston,  more  than  forty  years  ago,  successfullv 
reduced  an  old  dislocation  after  subcutaneous  division  of  all  tense 
bands,  and  that  in  1847  Blumhart  successfuly  practised  arthrotomy 
in  a  similar  case,  making  two  lateral  incisions,  and  dividing  through 
them  all  the  adhesions  that  opposed  reduction.  This  case  appears  to 
have  been  entirely  lost  sight  of,  and  it  was  not  until  thirty  years  later, 
in  1879,  that  Trendelenburg,^  in  a  paper  recommending  temporary 
division  of  the  olecranon  to  facilitate  operations  upon  the  elbow-joint, 
reported  a  case  of  incomplete  outward,  or  outward  and  backward,  dis- 
location of  both  bones  with  avulsion  of  the  epitrochlea  which  he  had 
treated  by  making  an  incision  along  the  tendon  of  the  biceps,  and  chis- 
elling away  enough  bone  from  the  lower  end  of  the  humerus  in  front 
of  the  coronoid  process  to  allow  flexion  to  a  right  angle  ;  the  result  was 
good  to  that  extent.  A  little  later  Volker^  reported  a  case  of  incom- 
plete outward  dislocation  of  the  left  elbow  of .  six  months'  standing  in 
a  boy  thirteen  years  old,  in  which,  after  division  of  the  olecranon,  he 
had  divided  the  adhesions,  dissected  away  the  new  tissues  in  the  sig- 
moid fossa,  and  had  then  been  able  to  reduce;  as  the  change  in  the 
shape  of  the  bones  favored  recurrence  he  removed  the  head  of  the 
radius.  His  incision  was  U-shaped,  the  sides  extending  along  the 
borders  of  the  triceps,  and  the  bottom  of  the  U  crossing  the  olecranon 
at  the  point  where  it  was  to  be  divided.  The  position  of  the  limb 
(anchylosis  in  almost  complete  extension)  and  the  evidences  of  serious 
pressure  upon  the  ulnar  nerve  were  important  factors  in  the  determi- 
nation to  operate.  He  was  so  pleased  with  the  result  tha  he  looked 
forward  with  confidence  to  the  adoption  of  the  method  in  all  old  dis- 
locations with  much  disability. 

Trendelenburg^  promptly  claimed  priority  in  the  suggestions  of  i)re- 
liminary  division  of  the  olecranon,  and  reported  a  case  of  backward 
dislocation  of  both  bones  of  eight  weeks'  standing  successfully  treated 
in  the  same  manner. 

In  1885  Nicoladoni*  published  a  short  paper  on  the  application  of 
arthrotomy  to  old  dislocations  of  various  joints,  and  included  in  it  the 
report  of  two  cases  in  which  he  had  practised  it  at  the  elbow.  The 
first  case  was  an  almost  complete  outward  dislocation  of  the  left  elbow 
in  a  lad  sixteen  years  old,  which  had  existed  for  eight  months  ;  the 
epitrochlea  was  broken  off  and  drawn  under  the  trochlea;  the  limb 
was  in  extension,  flexion  was  entirely  lost,  but  rotation  was  preserved. 
An  incision  eight  centimetres  long  was  made  in  front  along  the  inner 
border  of  the  trochlea,  and  through  this  the  fractured  ej)itrochlea  was 
removed  ;  a  second  incision  of  the  same  length  was  made  on  the  outer 
side  of  the  joint  through  which,  after  removal  of  a  small  piece  of  bone 
that  had  been  broken   from  the  condyles,  the  soft  parts  wx're  separated 

'  'PieiidekMibiirg:   Arcliiv  liif  kliii.  Cliir.,  1S7!>,  vol.  x.\iv.  ]i.  Tiio. 
''■  Volker:   Deutsche  Zfitsriiril't  I'iir  Chir..  ISriO.  vol.  xii.  p.  5-11. 
•'•  Ti-endelcnburK:  Ceiitralhlatt  fiir  Cliir.,  ISSO,  j).  KV.\. 
*  Nicohidoiii  :   Wiener  med.  Wocheiisclirift,  iyb5,  \i.  726. 


756 


DISLOCATIONS. 


from  the  radius  and  the  humerus;  then,  through  a  longitudinal  cut 
made  in  the  tendon  of  the  triceps,  the  adhesions  between  the  olecranon 
and  the  back  of  the  humerus  were  separated,  and  the  bones  were  then 
easily  restored  to  place.  The  wound  healed  after  slight  suppuration, 
passive  motion  was  begun  after  the  third  week,  and  the  patient  was 
dismissed  after  seven  and  a  half  weeks  with  the  elbow  flexed  and 
movable  through  an  arc  of  35  or  40  degrees.  Nine  months  later  he 
wrote  that  he  could  flex  and  extend  the  joint  freely,  but  that  rotation 
was  not  quite  so  free. 

The  second  patient  was  a  large,  powerful  man,  forty-one  years  old, 
with  a  backward  dislocation  that  had  existed  for  six  months.  The 
limb  was  almost  completely  extended  and  immovable;  there  was  some 
passive  rotation.  The  olecranon  was  situated  unusually  high.  Two 
lateral  incisions,  each  sixteen  centimetres  long,  were  made;  through 
the  first,  over  the  outer  condyle  in  front  of  the  head  of  the  radius,  the 


Fig.  431. 


Fig.  432. 


New  formation  of  bone  on  an  old 
unreduced  dislocation. 


Result  of  operative  reduction  of  old  dislocation. 


soft  parts  were  separated  from  the  bone,  leaving  the  periosteum  undis- 
turbed, into  the  trochlea  and  above  the  fossa  trochlearis  in  front  and 
behind  ;  through  the  second  incision,  on  the  inner  side  of  the  elbow, 
tiie  flexor  muscles  were  cut  away  close  in  front  of  the  epitrochlea,  and 
the  separation  of  the  soft  parts  from  the  bones  completed.  The  greater 
sigmoid  cavity  was  found  filled  with  hard  cicatricial  tissue,  which  was 
cut  and  scraped  away  after  separation  of  the  posterior  attachment  of 

Reduction  was  then  easily  made.     Recovery 


the  orbicular 


bgament. 


OLD   DISLOCATIONS   OF  TLIE   ELBOW.  757 

took  place  without  incident,  and  the  patient  was  dismissed  at  the  end 
of  four  weeks,  the  wounds  being  almost  healed.  There  was  good  active 
rotation,  but  very  little  flexion  ;  passively,  there  was  complete  extension 
and  flexion  to  a  right  angle. 

In  1886  I  operated  upon  a  five-months'  backward  dislocation  in  a 
girl  eleven  years  old  by  an  incision  on  the  outer  side  and  division  of 
the  olecranon.  My  attention  had  been  attracted  by  a  mass  of  bone 
attached  to  tlie  back  of  the  humerus  and  capping  the  head  of  the 
radius,  which  I  believed  to  be  of  new  formation  and  to  require  removal. 
The  conditions  found  on  exposure  (Fig.  431)  confirmed  this  opinion  ; 
the  mass  was  cut  away  and  the  dislocation  was  reduced.  The  case  is 
given  in  detail  in  the  Neio  York  Medical  Journal,  April  2,  1887.  The 
result  was  not  satisfactory,  recurrence  liaving  taken  place  inider  the 
dressing.  The  information  thus  gained  fixed  my  attention  upon  the 
im])ortance  of  the  mass  of  new  bone,  the  formation  of  which  I  attrib- 
uted to  the  strip))ing  up  of  the  periosteum  from  the  back  of  the  con- 
dyle by  the  displaced  head  of  the  radius,  enabled  me  properly  to 
estimate  the  difficulties,  and  encouraged  me  to  operate  in  other  cases. 
In  1891  ^  I  reported  seven  additional  cases,  in  five  of  wliich  I  had 
operated  with  good  results.  These  were  the  first  publications  in  which 
attention  was  called  to  this  obstacle  to  reduction.  I  have  since  operated 
upon  several  other  cases ;  the  results  have  all  been  flexion  within  a 
right  angle  and  extension  varying  from  120  to  170  degrees,  and  preser- 
vation of  rotation.    . 

The  operation^  is  done  by  a  long  incision  on  the  outer  side  exposing 
the  head  of  the  radius  and  the  mass  of  new  bone ;  the  latter  is  freely 
chiselled  away,  and  the  capitellum  exposed  by  free  division  of  the  soft 
parts,  keeping  the  knife  at  a  little  distance  from  the  bone  so  as  not  to 
damage  the  periosteum.  Through  the  incision  the  sigmoid  fossa  is 
cleared  of  fibrous  tissue.  A  second  incision,  about  four  inches  long, 
is  then  made  on  the  inner  side,  curving  close  behind  the  epitrochlea  or 
its  site,  the  ulnar  nerve  is  drawn  forward  and  the  olecranon  freed  ;  if 
the  epitrochlea  has  been  broken  off  and  displaced  upward  and  back- 
ward it  must  be  detached  from  the  humerus,  preserving  its  relations 
with  the  lateral  ligament.  The  cleaning  of  iho,  sigmoid  cavity  is  then 
completed.  If  the  attachments  of  the  olecranon  to  the  back  of  the 
humerus  have  been  thoroughly  divided  reduction  can  now  be  easily 
made  and  maintained,  unless  the  dislocation  has  existed  so  long  that 
the  flexor  muscles  of  the  hand  have  become  permanently  shortened,  in 
which  case  they  must  be  partly  divided  close  to  the  humerus. 

Vamossy^  reported  Nicoladoni's  experience — nine  cases  successfully 
treated  by  arthrotomy  between  1886  and  1890.  Kunn*  reports  Maydl's 
experience  of  five  cases  treated  by  resection  and  one  by  arthrotomy  ; 
Helferich''   reports  two  cases  successfully  reduced  by  the  aid  of  two 

'  Stiruson :  On  the  Treatment  of  Old  Dislocalioiis  of  the  Elbow,  New  York  Medical 
Journal,  October  24,  1891. 

'^  Stinison  :  Operative  Surgery,  third  edition,  1895,  p.  139. 
3  Vaniossy  :  Wiener  klin.  Wochenschrift,  December  11,  1890. 
*  Kunn  :  Int(!rnat.  klin.  Rundschau,  St^pteinber  (i,  1891. 
6  Helferich:  Deutsche  med.  Wochenschrift,  August  10,  189:j. 

52 


758  DISLOCA  TIONS. 

lateral  incisions,  and  Luksch  ^  reviews  the  subject  on  the  basis  of  60 
collected  cases. 

Many  surgeons  have  since  reported  their  experience  with  arthrotomy 
done  in  various  ways,  and  now  Professor  Dollinger^  comes  with  his 
large  personal  experience  of  45  cases  of  backward  dislocation,  25 
arthrotomies  and  20  resections,  detailed  notes  of  the  pathological  con- 
ditions, and  a  careful  study  of  the  indications.  All  his  operations, 
whether  ending  in  resection  or  reduction,  were  done  with  Kocher's  re- 
section incision  on  the  outer  side,  and  in  the  later  ones  he  detached  the 
external  lateral  ligament  from  the  humerus  with  a  chisel  instead  of 
dividing  it.  Through  this  incision  the  ends  of  the  bones  were  pro- 
truded and  examined  ;  if  reduction  was  decided  upon,  the  articular  sur- 
faces were  thoroughly  cleared  of  adherent  tissues,  nesv  growths  of  bone 
were  cut  away,  and  restraining  bands  divided  ;  if  resection  was  chosen, 
the  end  of  the  humerus  alone  was  removed  below  the  condyles.  The 
condition  after  one  or  more  years  was  ascertained  in  15  of  the  25  re- 
ductions :  3  were  stiff,  12  were  useful  joints  movable  within  ranges  of 
from  40°  to  120°.  The  three  stiff  ones  were  all  primarily  complicated 
cases  in  which  resection  might  properly  have  been  chosen. 

The  grounds  upon  which  the  choice  of  a  method  of  treatment  of  an 
old  backward  dislocation  rests  seem  well  established.  In  the  young, 
in  whom  the  dislocation  is  so  common,  the  new  formation  of  bone  at 
the  back  of  the  humerus  capping  the  head  of  the  radius  takes  place 
very  promptly  in  most  cases — I  have  seen  it  well  formed  after  three 
weeks ;  its  presence,  shown  by  palpation  or  the  .T-rays,  seems  to  me  a 
positive  indication  for  its  removal  by  arthrotomy.  In  all  cases,  old 
and  young,  the  sigmoid  fossa  of  the  olecranon  is  likely  to  be  occupied 
within  a  month  by  firmly  adherent  portions  of  the  capsule,  which,  if 
not  removed,  would  leave  reduction  incomplete  and  would  diminish  the 
mobility  of  the  joint  thereafter;  and  after  the  lapse  of  two  months 
(Dollinger)  the  articular  cartilage  of  the  humerus  is  likely  to  be  seri- 
ously degenerated  or  detached.  Consequently,  reduction  by  manipu- 
lation, after  the  lapse  of  three  weeks  in  the  young  or  a  month  or  two 
in  the  old,  is  unlikely,  even  if  successful,  to  give  a  better  functional 
result  than  may  properly  be  expected  from  a  well-done  arthrotomy  ; 
but  suppuration  after  arthrotomy  gives  almost  surely  a  stiff  joint.  If 
on  inspection  the  joint  is  found  unfitted  for  future  service  by  fractures, 
loss  of  articular  cartilage,  softening  or  erosion  of  the  bones,  then  resec- 
tion is  generally  indicated.  In  youth  the  desirability  of  preserving  the 
epiphyses,  in  order  that  the  growth  of  the  limb  in  length  may  not  be 
checked,  is  a  contra-indication ;  and  sometimes  in  working-people  a 
stiff  elbow  at  a  favorable  angle  is  better  than  a  too  loose  joint.  In  re- 
secting it  is  desirable  when  practicable  to  remove  only  the  lower  end 
of  the  humerus,  in  order  that  the  joint  may  be  under  better  control, 
than  it  usually  is  when  the  olecranon  and  head  of  the  radius  also  have 
been  taken,  even  if  the  mobility  should  be  restricted  or  even  lost  in 
consequence. 

1  Luksch :  Deutsche  Zeit.  fiir  Chir.,  1900,  vol.  Ivii.  p.  413. 
*  Dollinger:  Ergebnisse  der  Chir.  und  Orthop.,  1911,  vol.  iii. 


DISLOCATIONS  OF  THE  ELBOW.  759 

In  old  incomplete  outward  lateral  dislocations  little  is  to  be  hoped  for 
from  forcible  subcutaneous  rupture  of  the  adhesions,  for  the  common 
interposition  of  the  fractured  epitrochlea  cannot  thus  be  overcome,  and 
the  probabilities  are  decidedly  against  the  success  of  an  attempt  to 
remove  by  this  means  the  cicatricial  obstacles  on  the  inner  side.  The 
choice  lies  between  improving  the  attitude  bj  forcible  flexion,  if  the 
limb  is  extended,  and  arthrotomy,  the  internal  incision  being  made  in 
front  of  the  trochlea  rather  than  upon  its  side. 

In  old  dislocations  of  the  radius  alone,  in  which  partial  or  complete 
anchylosis  renders  an  operation  desirable,  the  examples  quoted  in  the 
preceding  chapter  may  serve  as  guides.  In  those  cases  in  M'hich  the 
dislocation  has  occurred  in  childhood  and  has  been  followed  by  exag- 
gerated growth  in  length  of  the  radius  excision  of  its  head  is  the  only 
suitable  operation,  and  in  other  cases  it  is  probably  the  means  most 
likely  to  improve  function. 

SprengeP  reports  a  case  of  dislocation  l)ackward  and  outward  of  the 
head  of  the  radius  of  five  weeks'  standing  in  a  boy  six  years  old  in 
which  he  effected  reduction  and  obtained  a  perfect  functional  result  by 
arthrotomy  and  removal  of  a  portion  of  the  back  of  the  capsule  that 
was  interposed  betM'een  the  head  of  the  radius  and  the  ulna.  He  made 
an  anterior  incision  along  the  edge  of  the  supinator  longus,  exposed 
the  musculo-spiral  nerve  and  its  two  branches  and  drew  them  outward 
with  the  outer  flap  ;  by  this  means  the  capsule  was  freely  exposed  to 
view,  and  he  was  enabled  to  see  that  the  rent  was  on  its  outer  side,  and 
then  by  drawing  the  head  of  the  radius  outward  with  a  sharp  hook  the 
obstacle  to  reduction  was  found  to  be  a  fold  of  the  posterior  portion  of 
the  capsule  (probably  part  of  the  annular  ligament)  interposed  between 
the  radius  and  ulna,  and  firmly  adherent  to  the  lesser  sigmoid  cavity. 
After  having  liberated  this  fold  he  was  able  to  replace  the  head  of  the 
radius  and  to  close  with  catgut  sutures  the  rent  in  the  capsule  except 
over  a  small  space  on  the  outer  side. 

He  refers  to  a  case  of  backward  dislocation  of  the  head  of  the  radius 
in  which  he  obtained  a  similar  success  by  arthrotomy  and  separation  of 
the  capsule  from  the  upper  surface  of  the  radius. 

CONGENITAL    AND    PATHOLOGICAL    DISLOCATIONS. 

Although  a  considerable  number  of  cases  have  been  reported  as  con- 
genital dislocations  of  the  upper  end  of  the  radius,  yet  in  many  of  them 
the  proof  that  the  deformity  existed  at  birth  is  defective ;  in  some 
it  was  noticed  at  so  early  a  period  that  the  probability  of  its  con- 
genital existence  is  great ;  in  others,  and  even  in  some  in  which  both 
radii  were  affected,  the  displacement  can  be  referred  with  equal  plausi- 
bility to  causes  operating  after  birth,  and  the  alterations  in  the  shape 
of  the  bones  to  the  effect  of  the  displacement  and  the  changed  func- 
tional conditions. 

To  the  13  alleged  cases  briefly  quoted  and  analyzed  by  Malgaigne, 
9  of  which  are  quoted  in  detail  by  Gurlt,"  may  be  added  several  that 

1  Sprengel :  Centralblatt  fur  Chirurgie,  1886,  p.  153. 

'  Gurlt :  Beitrage  zur  Vergleich.  path.  Anat.  der  Gelenkkrankheiten,  1853,  p.  317. 


760  DISLOCATIONS. 

have  been  since  reported,  those  of  Humpliry,^  Hayem/  Mitscherlich,^ 
Allen,^  Hamilton/  Phillips/  Pye-Smith/  Heele/  and  Herskovits.' 
In  addition  is  a  case,  a  dislocation  forward,  observed  and  briefly  men- 
tioned by  Kronlein.^** 

The  first  4  were  examined  post  mortem,  the  others  only  clinically. 
In  5  of  them  the  dislocation  was  backward,  in  3  forward ;  in  all  both 
radii  were  dislocated.  Humphry's,  Hayem's,  Allen's,  and  Hersko- 
vit's  were  in  adults,  of  whom  no  previous  history  was  obtained.  In 
Humphry's  the  lower  part  of  the  left  ulna  was  lacking,  evidently 
because  of  defective  development ;  the  right  ulna  was  firmly  anchy- 
losed  to  the  humerus  nearly  at  a  right  angle,  and  was  eight  inches  long, 
its  lower  end  was  well  formed  and  was  on  the  usual  level  with  the 
radius ;  the  radius  was  also  eight  inches  long,  and  its  head  was  dis- 
placed upward  and  rested  against  "  the  forepart  of  the  ridge  that 
ascends  from  the  outer  condyle  to  the  shaft,"  it  was  somewhat  irregu- 
lar in  shape,  and  its  extra  length  was  developed  in  its  shaft  and  not  in 
its  neck  as  in  several  of  the  other  reported  cases.  The  trochlea  of  the 
humerus  was  imperfect.  The  displacement  upward  was  clearly  the 
result  of  the  elongation  of  the  radius,  whatever  the  cause  of  the  orig- 
inal displacement  from  contact  with  the  capitellum  may  have  been. 

Mitscherlich's  patient  was  a  girl  six  years  old  who  had  been  born 
with  clubfoot ;  both  elbows  were  deformed,  and  this  defect  was  thought 
also  to  have  existed  from  birth.  The  head  of  the  radius  could  be  felt 
in  front  of  the  outer  half  of  the  coronoid  process ;  extension  was  per- 
fect, but  flexion  was  limited  on  the  right  side  to  an  angle  of  70  degrees 
and  on  the  left  to  one  of  110  degrees;  both  hands  were  supinated. 
Excision  of  the  left  elbow  was  done  by  von  Langenbeck  with  the 
object  of  increasing  its  range  of  motion,  and  the  child  died  in  conse- 
quence of  the  operation.  The  specimen  showed  that  the  trochlear 
surface  of  the  humerus  was  narrowed  in  front  by  extension  upon  it  of 
the  exceptionally  large  circular  surface  for  the  head  of  the  radius.  The 
articular  surface  of  the  ulna  was  normal,  but  the  radius  was  not  in 
contact  with  it. 

Allen's  specimen  was  taken  from  the  body  of  an  elderly  man  with- 
out histor3\  Both  elbows  were  affected  ;  flexion  was  normal,  extension 
possible  only  to  a  right  angle ;  rotation  was  entirely  lost,  the  limbs 
being  fixed  in  pronation.  Both  radii  were  displaced  backward,  but 
only  the  left  elbow  is  described  in  detail.  The  specimen  was  not  pre- 
sented as  an  example  of  congenital  dislocation,  but  only  to  show  the 
changes  effected  in  the  bones  in  consequence  of  unreduced  dislocation 
in  early  life.  These  changes  modified  the  shape  of  the  lower  end  of 
the  humerus  and  of  the  radius.  The  radius  crossed  the  front  of  the 
ulna  and  was  united  with  it  by  bony  union  for  a  distance  of  about  three 

1  Humphry :  Medico-Chirurgical  Transactions,  vol.  xlv.  p.  296. 
*  Hayem  :  Bull,  de  la  Societe  Anatomique,  1864,  p.  56. 
3  Mitscherlich  :  Arch,  fiir  klin.  Chir.,  1865,  vol.  vi.  p.  218. 

■*  Allen  :  Glasgow  Medical  Journal,  1880,  vol.  xiv.  p.  44.         ^  Hamilton  :  Loc.  cit.,  p.  888. 
«  Phillips:  British  Medical  Journal,  18813,  vol.  i.  p.  773. 
'  Pye-Smith  :  Lancet,  1883,  vol.  ii.  p.  993. 
»  Heele :  Lancet,  1886,  vol.  ii.  p.  249. 
9  Herskovits:  Wiener  med.  Presse,  February  12,  1888. 
1"  Krouleiu  :  Deutsche  Chirurgie,  Lief.  26,  p."  97. 


DISLOCATIONS  OF  THE  ELBOW.  761 

inches  at  their  upper  part ;  below  this  part  the  shaft  of  the  ratlins  was 
much  thickened.  The  neck  of  the  radius  was  one  and  a  half  inches 
long,  so  that  the  head  was  carried  well  upward  behind  the  humerus  on 
the  inner  side  of  the  olecranon,  and  this  overriding  was  further  increased 
by  the  abnormal  growth  of  the  external  condyle  downward  and  out- 
ward, the  extent  downward  of  the  growth  being  estimated  at  half  an 
inch.  The  trochlear  surface  was  deformed,  mainly  by  the  loss  of  much 
of  its  inner  lip.  The  olecranon  fossa  was  so  far  filled  up  that  the  sep- 
tum between  it  and  the  coronoid  fossa  was  one-third  of  an  inch  thick. 
The  shaft  of  the  ulna  was  small ;  its  lower  end  was  normal  and  pre- 
served the  usual  relations  with  the  radius.  The  specimen  appears 
closely  to  resemble  those  of  the  earlier  cases  reported  by  Sandifort, 
Dubois,  and  Verneuil,  and  has  as  much,  or  as  little,  reason  to  be 
thought  congenital  as  most  of  the  others.  It  is  of  value  in  the  inter- 
pretation of  the  changes  observed  in  other  specimens. 

Herskovits's  patient  was  a  man  twenty-one  years  old  ;  the  head  of 
each  radius  was  displaced  backward  and  outward,  the  capitellum  small. 
Flexion  was  nearly  complete,  extension  to  135  degrees,  pronation  com- 
plete, supination  lost.     No  history  of  injury. 

For  details  of  other  cases,  see  first  edition. 

The  arguments  upon  which  the  attribution  of  a  congenital  character 
was  based  in  most  of  the  older  cases  and  in  those  of  Humphry  and 
Hayem,  and  which  apply  equally  well  to  Allen's,  are  the  existence  of 
the  deformity  on  both  sides  and  the  changes  in  the  shape  of  the  artic- 
ular ends  of  the  bones ;  in  Humphry's  and  in  Deville's  there  is  in 
addition  the  lack  of  the  lower  part  of  the  ulna. 

The  irregularities  in  the  bones  may,  in  part  at  least,  be  fairly  attrib- 
uted to  the  change  in  their  relations,  especially  the  very  notable  one  of 
elongation  of  the  neck  of  the  radius  reported  in  several  cases.  This 
is  in  keeping  with  similar  instances  of  overgrowth  at  other  points 
where  the  normal  conditions  of  pressure  have  been  lost,  and  with  the 
coincident  elongation  downward  of  the  external  condyle  of  the  humerus 
noted  in  Allen's  case  and  in  one  of  R.  W.  Smith  quoted  by  Gnrlt.^ 
It  requires  only  that  the  displacement  should  occur  before  the  groMth 
of  the  skeleton  is  complete. 

Blodgett  ^  has  recently  reported  a  case  and  collected  50  others.  The 
displacement  in  one-eighth  was  outward,  in  the  others  about  equally 
divided  between  backward  and  forward.  Supination  was  lost  or 
much  restricted  in  nearly  all ;  flexion  restricted  when  the  displacement 
was  forward,  extension  when  it  was  backward.  Elongation  of  the 
upper  end  of  the  radius  existed  in  three-fourths,  bony  fusion  with  the 
ulna  in  one-third.  In  nearly  half  of  the  cases  some  other  deformity 
was  present,  most  often  partial  deficiency  of  the  radius  or  ulna.  In  3 
cases  the  head  of  the  radius  was  excised,  with  gain  of  flexion  and 
extension  in  2  and  of  rotation  also  in  1  of  them. 

Permanent  retraction  of  the  pronators,  due  to  prolonged  mainte- 
nance of  the  attitude,  must  be  a  serious  obstacle  to  the  establishment 
of  supination. 

1  Gurlt:  Loc.  cit.,  p.  320. 

2  Blodgett:  Am.  Jouru.  Orthop.  Surg.,  1906,  vol.  3,  p.  253. 


762  •         DISLOCATIONS. 

The  only  recorded  case  of  dislocation  of  both  bones  of  the  forearm 
at  birth  is  one  reported  by  Chaussier  and  quoted  by  Pingaud.^  A 
young  woman  during  the  ninth  month  of  pregnancy  felt  her  child 
move  so  vigorously  that  she  almost  lost  consciousness.  The  move- 
ments were  repeated  three  times  in  the  course  often  minutes;  delivery 
took  place  normally  at  term.  The  child  was  weak  and  presented  a 
complete  dislocation  of  the  forearm  backward.  Malgaigne  thought  it 
probable  that  the  lesion  was  produced,  not  by  the  convulsive  action  of 
the  muscles,  but  by  the  striking  of  the  limb  against  the  wall  of  the 
uterus. 

A  few  instances  of  dislocation  due  to  pathological  changes  within 
the  joint,  such  as  fungous  arthritis  or  relaxation  of  the  ligaments  in 
the  course  of  an  acute  illness,  have  been  reported. 

1  Pingaud :  Diet.  Encyclopedique  des  So.  Med.,  art.  Coude,  p.  606. 


CHAPTER  XLVIIL 

DISLOCATIONS  AT  THE  WRIST. 

Dislocations  of  the  Lower  Radio-ulnar  Joint — of  the  Radio-carpal  Joint — of 
the  Carpal  Bones — Carpo-metacarpal  Dislocations. 

DISLOCATIONS  OF  THE  LOWER  RADIOULNAR  JOINT. 

These  dislocations,  obscurely  mentioned  by  the  earlier  writers,  were 
first  described,  according  to  Malgaigne,  in  1771,  by  Desault,  who 
reported  five  cases  and  said  he  had  observed  a  great  number  of  others. 
He  spoke  of  the  injury  as  a  dislocation  of  the  radius,  but  Boyer  and 
Dupuytren  preferred  to  call  it  a  dislocation  of  the  ulna,  and  their  choice 
has  been  generally  accepted  and  followed.  Both  traumatic  and  patho- 
logical forms  have  been  described.  The  reported  cases  are  com- 
paratively few  if  those  cases  are  excluded  in  which  the  injury  is  a 
complication  of  a  fracture  of  the  lower  end  of  the  radius.  Few  surgeons 
who  have  reported  their  experience  have  seen  more  than  a  single  case. 
Tillmanns^  collected  48  cases  in  addition  to  one  observed  by  himself, 
of  which  the  dislocation  of  the  ulna  was  forward  in  16,  backward  in  18, 
and  inward  in  9,  and  in  5  the  direction  was  not  stated;  but  in  3  of  the 
first  group,  8  of  the  second,  all  of  the  third,  and  1  of  the  fourth,  there 
,was  also  fracture  of  the  radius,  and  in  4  others  the  ulna  perforated 
the  skin  and  there  is  reason  to  think  the  radius  also  was  fractured. 
Excluding  the  cases  complicated  by  fracture  and  including  only  3  of 
Desault's  5,  there  remain  12  dislocations  forward  and  10  backward; 
to  these  may  be  added  2  backward  and  3  forward  seen  or  collected  by 
Hamilton,  3  forward  collected  by  Poinsot,  1  forward  of  my  own,^ 
'3  forward  by  Holst,^  Leuben,^  and  Thon,^  and  3  backward  by  Ridlon,^ 
Horrocks,'^  and  Berger,^  making  a  total  of  these  two  varieties  of  22 
forward  and  15  backward.  The  reported  dislocations  inward  or,  more 
strictly  speaking,  downward  and  inward,  are  really  dislocations  of  the 
broken  end  of  the  radius  and  the  attached  carpus  upward;  to  these 
may  be  added  also  the  few  cases  of  dislocation  of  the  head  of  the  radius 
(q.  V.)  in  which  the  entire  bone  has  been  displaced  upward  along  the 
ulna. 

Dislocations  Backward  (of  the  Ulna). 

The  cause  in  most  of  the  cases  tabulated  above  was  exaggerated 
pronation  of  the  wrist;  in  some  the  mechanism  is  not  indicated,  and 

1  Tillmanns:  Arch,  der  Heilkunde,  1«74,  vol.  xv,  p.  249. 
^Stimson:   New  York  Medical  Journal,   May  25,   1889. 
3  Hoist:  Centralbl.  fiir  Chir.,  .June  20,   1891. 
^Leuveii:  Ztlblatt.  fiir  Chir.,   1906,   p.    1128. 
6  Thon:   Deutsche  Zeitschrift  fiir  Chir.,  vol.  84,  parts  1  and  .3. 
«  Ridlon:   New  York   Medical  Journal,   April  25,    1891. 

^  Horrocks:  Lancet,  June  27,  1891.  »  Bcrger:  L'Union  Med.,  April  13,  1895. 

(  763  ) 


764  DISLOCATIONS. 

in  others  it  is  not  clear.  Possibly  some  of  the  cases  of  its  alleged  pro- 
duction in  infants  by  traction  upon  or  pronation  of  the  hand  belong 
among  dislocations  of  the  radius  by  elongation  (q.  v.).  Sometimes  the 
exaggerated  pronation  has  been  effected  by  external  violence,  as  in 
Boyer's  case,  in  which  a  lad  engaged  his  hand  between  the  spokes  of  a 
moving  wheel ;  sometimes  by  muscular  action,  as  in  one  of  Desault's, 
a  washerwoman  who  was  wringing  clothes,  or  in  one  of  Rognetta's,  a 
carpenter  who  was  drilling  a  hole  in  a  plank;  Dalecharap's  patient 
was  bitten  at  the  wrist  by  a  horse. 

The  pathology  has  not  been  shown  by  direct  examination  of  either 
recent  or  old  cases,  and  the  only  experiments  bearing  upon  it  are  those 
of  Goyrand,  quoted  in  Chapter  XLYI.,  and  they  show  only  that  by 
exaggerated  pronation  the  triangular  fibro-cartilage  uniting  the  radius 
and  ulna  could  be  carried  so  far  forward  as  to  clear  the  end  of  the  ulna 
entirely ;  he  did  not  succeed  in  producing  by  this  means  a  dislocation 
that  would  maintain  itself  without  the  aid  of  pressure  upon  the  hand. 
It  seems  probable  that  in  the  clinical  cases  there  was  also  rupture  of 
the  posterior  radio-ulnar  ligament. 

Symptoms.  The  hand  is  slightly  or  markedly  pronated  ;  its  adduc- 
tion has  been  noted  by  some,  and  diminution  of  the  transverse  diameter 
of  the  wrist  by  others.  Flexion  and  extension  of  the  wrist  are  free  ; 
supination  difficult. 

The  deformity  consists  in  a  marked  projection  of  the  lower  end  of 
the  ulna  on  the  back  of  the  wrist,  and  a  corresponding  depression  in 
front ;  the  ulna  may,  in  addition,  slightly  overlap  the  end  of  the  radius, 
so  that  its  axis  if  prolonged  downward  would  pass  to  the  middle  finger. 

In  connection  with  these  may  be  mentioned  a  unique  case  reported 
by  Schmid  ^  of  dislocation  of  the  radius  forward  from  the  ulna  and 
carpus,  caused  by  a  fall  upon  the  hand. 

The  diagnosis  appears  to  be  easy.  Malgaigne  calls  attention  to  the 
danger  of  mistaking  the  cause  for  the  effect  in  old  cases  in  which  the 
dislocation  follows  a  chronic  arthritis,  and  also  of  overlooking  an  asso- 
ciated fracture  of  the  radius. 

Reduction.  Reduction  has  always  been  readily  effected  by  direct 
pressure  on  the  ulna,  aided  sometimes  by  abduction  or  supination  of 
the  hand ;  occasionally  supination  alone  has  been  sufficient.  Even  in 
old  cases — sixty  days — reduction  has  been  easily  made. 

Recurrence  has  been  noted  in  three  cases.  In  one  of  Hamilton's  the 
dislocation  had  existed  twenty  years,  but  the  movements  of  the  limb 
were  perfect. 

Dislocations  Forward  (of  the    Ulna). 

Dislocation  of  the  lower  end  of  the  ulna  forward  appears  commonly 
to  have  been  caused  by  direct  violence  acting  in  opposite  directions  upon 
the  lower  ends  of  the  radius  and  ulna  while  the  hand  was  more  or  less 
supinated.  It  does  not  clearly  appear  that  the  cause  has  ever  acted  by 
carrying  the  movement  of  supination  beyond  its  normal  limit,  although 
it  is  not  improbable  that  this  was  the  case  in  one  or  two  instances. 

No  post-mortem  examination  has  been  reported,  and  the  jjathology 
of  the  injury  can,  therefore,  only  be  inferred.     Desault,  however,  met 

'  Schmid  :  Correspoudeuz-Blatt  d.  Wiirttemberg  iirztl.  Landvereins,  November  16, 1892. 


DISLOCATIONS  AT  THE   WRIST.  765 

with  a  specimen  of  an  old  dislocation  in  the  cadaver  of  a  man  sixty 
years  old ;  the  hand  could  not  be  extended,  and  rotation  was  very 
limited.  The  sigmoid  cavity  of  the  radius  was  filled  with  cellular 
tissue ;  the  head  of  the  ulna,  situated  in  front  of  this  cavity,  rested  on 
a  sesamoid  bone  to  which  it  w^as  attached  by  a  capsular  ligament. 
Other  injuries  had  contributed  to  the  loss  of  motion. 

In  an  entirely  unique  case  reported  by  Valleteau '  the  dislocation 
was  compound.  The  patient's  forearm  had  been  caught  between  the 
spokes  of  a  moving  wheel ;  the  ulna  projected  twenty-eight  lines 
through  the  skin,  crossing  the  front  of  the  radius,  which  appears  not 
to  have  been  broken. 

Symptoms.  The  forearm  is  partly  pronated  or  in  varying  degrees 
of  supination,  the  wrist  flexed  or  extended,  rotation  difficult  and  pain- 
ful. The  lower  end  of  the  ulna  is  prominent  in  front,  with  a  corre- 
sponding depression  behind,  and  sometimes  displaced  toward  the  outer 
side  so  that  it  overlaps  the  front  of  the  radius  and  its  axis  is  directed 
toward  the  middle  of  the  hand.  The  radius  maintains  its  relations 
with  the  carpus.  In  my  case  I  could  not  determine  the  position  of 
the  triangular  fibro-cartilage. 

The  diagnosis  is  easy,  but  search  should  be  made,  as  in  the  preced- 
ing variety,  for  the  possible  coexistence  of  a  fracture  of  the  radius. 

The  best  method  of  reduction  appears  to  be  by  direct  pressure  upon 
the  ulna  and  counter-pressure  on  the  radius. 

Dislocations  Inward  and   Downward  (of  the  Ulna). 

Dislocations  inward  and  downward  have  been  observed  in  connec- 
tion with  fracture  of  the  radius  or,  very  rarely,  with  dislocation  of  its 
upper  end,  and  are  to  be  deemed  complications  or  incidents  of  the 
other  and  m.ore  important  injury. 

In  like  manner,  the  serious  complication  of  perforation  of  the  skin 
by  the  ulna  has  occurred  only  once  except  in  connection  with  fracture 
of  the  radius. 

Pathological  dislocations  have  been  reported  as  the  consequence  of 
chronic  suppurative  arthritis  and  also  of  non-suppurative  arthritis 
provoked  by  a  sprain  or  by  a  fracture  of  the  radius.  Possibly  the 
case  reported  by  Rognetta,^  of  a  negro  who  suffered  from  an  habitual 
dislocation  of  the  ulna  backward  gradually  produced  by  the  effi?cts  of 
his  occupation  as  a  woodsawyer,  belongs  in  this  category,  the  ligaments 
having  become  relaxed  in  consequence  of  an  arthritis  set  up  by  the 
constantly  repeated  mechanical  violence  of  the  movement. 

DISLOCATIONS  OF  THE  RADIO-CARPAL  JOINT. 

These  dislocations,  long  thought  to  be  common  because  fracture  of 
the  lower  end  of  the  radius  was  hal)itually  su])p()sed  to  be  a  disloca- 
tion until  Dupuytren  forced  a  recognition  of  the  error,  are  now  known 
to  be  of  infrequent  occurrence.  Dupuytren,  in  the  vigor  of  his  cor- 
rection of  the  error,  went  to  the  other  extreme  and  jironounced  them 
unknown  or  of  very  great  rarity,  and  this  assertion   has  colored  the 

1  Valleteau  :  Gazette  Medicale,  183«,  p.  250. 

2  Rognetta :  Archives  gen.  do  Med.,  1«34,  vol.  v.  p.  396. 


766  DISLOCATIONS. 

general  opinion  concerning  their  frequency  even  to  the  present  time. 
The  statistics  that  have  since  been  collected  are  not  entirely  trust- 
worthy, perhaps,  for  the  error  in  diagnosis  appears  still  to  be  made 
and  not  all  reported  cases  can  be  unhesitatingly  accepted,  but  there  is 
reason  to  think  that  the  rarity  is  not  very  great,  and  there  are  enough 
well-authenticated  cases  to  make  it  possible  to  trace  a  general  descrip- 
tion of  the  injury.  Malgaigne  collected  14  cases,  8  of  backward,  6  of 
forward  dislocation.  Parker'  collected  33  cases,  23  backward  and  10 
forward.  Tillmanns,^  1874,  collected  24,  13  backward  and  10  for- 
ward; and  Servier^  in  1880  collected  26  besides  1  observed  by  him- 
self, 13  backward,  13  forward,  and  1  outward,  of  which  19  were  not 
contained  in  Tillmann's  paper.  I  saw  1  and  collected  13  cases  pub- 
lished between  1880  and  1887,  12  backward  and  2  forward,  and  it  is 
worthy  of  note  that  5  of  these  were  reported  in  the  British  Medical 
Journal  within  six  weeks  of  one  another,  March  and  April,  1880,  the 
reports  of  the  last  4  having  been  called  out  by  that  of  the  first. 
Albert  speaks  of  5  within  his  knowledge  or  observation.  Even  sup- 
posing Parker's  33  to  include  all  of  Malgaigne's  and  Tillmanns's,  and 
counting  19  of  Servier's,  this  would  still  give  a  total  of  about  70  cases 
more  or  less  well  authenticated,  the  correctness  of  the  diagnosis  in  a 
number  of  them  being  entirely  beyond  question. 

The  necessity  of  receiving  with  some  caution  those  cases  that  have 
been  observed  clinically  and  reported  with  scanty  detail  is  shown  by 
the  errors  in  diagnosis  that  have  been  made  by  experienced  surgeons 
fully  aware  of  the  difficulty.  Malgaigne  *  narrates  three  striking  cases. 
At  the  time  when  Dupuytren  was  first  questioning  the  correctness  of 
the  diagnosis  in  which  fracture  of  the  lower  end  of  the  radius  was 
habitually  taken  to  be  a  backward  dislocation  of  the  wrist,  a  patient 
presenting  all  the  usual  signs  of  this  injury  died  at  the  Hotel  Dieu. 
Pelletan  declared  it  to  be  a  dislocation,  Dupuytren  a  fracture,  and  the 
former  did  not  vary  from  his  opinion  until  after  the  last  stroke  of  the 
scalpel  had  exposed  the  bone  and  showed  the  injury  to  be  a  fracture 
with  crushing  of  the  lower  end  of  the  radius.  In  1834  Roux  made 
the  diagnosis  of  dislocation  backward  in  the  case  of  a  child  that  had 
fallen  from  a  tree ;  again  dissection  proved  it  to  be  a  fracture,  with 
separation  of  the  epiphysis.  Still  more  remarkable  was  a  case  reported 
by  Chassaignac^  in  which  he  excised  the  projecting  ends  of  the  radius 
and  ulna,  thinking  the  case  was  dislocation  ;  on  careful  examination  it 
proved  to  be  a  separation  of  the  epiphysis  of  the  radius.  The  diffi- 
culty is  probably  not  so  great  in  dislocations  of  the  carpus  forward. 

The  dislocation  may  be  complete  or  incomplete  backward  or  for- 
ward, and  in  one  case  was  incomplete  outward ;  it  may  be  simple  or 
compound,  or  associated  with  fracture  of  the  radius  or  ulna.  Appar- 
ently fracture  of  the  edge  of  the  articular  surface  of  the  radius  on  the 
side  toward  which  the  carpus  is  dislocated  is  not  infrequent;  such 
fracture  of  the  posterior  lip  of  the  radius  is  known  in  this  country  as 
"Barton's  fracture,"  but  it  appears  to  me  properly  to  belong  among 

*  Parker:  Transactions  of  the  South  Carolina  Medical    Association.      Abstract  in  the 
New  York  Medical  Record,  1876,  vol.  vi.  p.  396. 

'■^  Tillnianns  :  Loc.  cit.  •''  Servier  :  Gazette  Hebdom.,  1880,  p.  211. 

*  Malgaigne  :  Loc.  cit.,  p.  703. 

^  Chassaiguac :  Bull,  de  la  Societe  de  Chir.,  1868,  p.  225. 


DISLOCATIONS  AT  THE   WRIST.  767 

the  dislocations,  the  fracture  being  only  an  incident  or  complication. 
The  incomplete  dislocations  are  mainly  those  in  which  only  the  outer 
portion  of  the  carpus,  the  scaphoid  and  semilunaris,  is  dislocated  from 
the  radius,  while  the  inner  portion  maintains  its  relations  with  the 
triangular  fibro-cartilage  and  ulna ;  this  variety  appears  to  be  produced 
by  a  movement  of  rotation  (pronation  or  supination)  in  which  either 
the  radius  or  the  carpus  is  kept  stationary  while  the  other  moves  away 
from  it ;  it  appears  to  be  sometimes  associated  with  disturbance  of  the 
relations  of  the  lower  radio-ulnar  joint. 

It  is  interesting  to  note  that  in  several  cases  the  semilunar  and  ad- 
joining portion  of  the  fractured  scaphoid  remained  in  relation  with  the 
radius,  the  dislocation  taking  place  beyond  them.  The  line  of  separa- 
tion within  the  carpus  is  thus  identical  with  that  of  many  midcarpal 
fracture-dislocations,  the  difference  between  the  two  being  that  the  main 
portion  of  the  carpus  is  displaced  in  the  former  and  the  small  portion 
in  the  latter.  Apparently  the  mechanism  of  the  separation  within  the 
carpus  is  the  same  in  both,  and  the  dislocation  of  one  or  the  other 
portion  is  the  result  of  variations  in  the  direction  of  the  force. 

In  addition  to  the  traumatic,  a  few  pathological  and  congenital  disloca- 
tions have  been  reported. 

Dislocations  Backward. 

Causes.  The  causes  of  this  dislocation  are  characterized  by  great 
violence,  as  a  fall  from  a  height  upon  the  palm  of  the  hand ;  in  some 
cases  the  wrist  appears  to  have  been  flexed  forward,  "  doubled  under  " 
the  patient,  in  a  fall  while  walking,  or  from  a  slight  elevation. 

In  two  almost  identical  cases,  Billroth  ^  and  Rydygier,^  the  mode  of 
production  is  clearly  shown  ;  in  the  former,  the  patient,  while  pressing 
with  the  palm  of  his  hand  against  a  railway  car  in  an  effort  to 
arrest  its  motion,  was  struck  upon  the  back  of  the  elbow  by  another 
car  moving  in  the  opposite  direction,  and  a  compound  dislocation  of 
the  wrist  was  produced,  the  articular  surfaces  of  the  radius  and  ulna 
projecting  through  the  skin  on  the  palmar  surface.  Rydygier's  patient 
was  caught  in  the  same  way  between  a  wagon  and  a  wall  alongside  of 
which  it  was  moving. 

Pathology.  The  pathology  is  illustrated  by  a  number  of  post-mortem 
examinations,  and  by  some  cases  complicated  by  wounds  which  per- 
mitted direct  examination  of  the  joint.  The  autopsy  that  has  been 
reported  with  most  detail  is  that  of  a  case  observed  by  Voillemier.^ 
The  patient  was  a  man  twenty-seven  years  old,  who  had  fallen  from  the 
third  story  of  a  building,  and  received  injuries  which  caused  his  death 
in  four  hours.  The  violence  that  caused  the  dislocation  of  the  wrist 
Avas  apparently  received  upon  the  palm  of  the  hand  wdiile  in  dorsal 
flexion.  The  external  and  posterior  ligaments  were  ruptured,  the 
anterior  was  torn  away  from  the  radius,  and  the  internal  was  intact 
but  was  separated  from  the  ulna  by  avulsion  of  its  styloid  process. 
The  tendons  and  muscles  of  the  back  of  the  forearm  were  riot  torn, 
but  had  been  stripped  off  the  radius,  bringing  with  tliem  the  perios- 
teum and  small  pieces  of  attached  bone.     The  superficial  flexor  muscle 

1  Billroth:  Arch,  fiir  klin.  Chir.,  vol.  x.  p.  601,  quoted  by  Tilliuiiuns. 
'■^  Rydygier  :   Deutsche  Zeitschrii't  fiir  Chir.,  1881,  vol.  xv.  p.  2H9. 
•*  Voilicmier:   Arch.  gcii.  de  Med.,  IS.S!),  vol.  vi.  p.  401. 


768  DISLOCATIONS. 

was  widely  perforated  and  torn  by  the  styloid  process  of  the  radius  at 
its  inner  portion,  that  corresponding  to  the  tendons  of  the  ring  and  little 
fingers,  the  remainder  being  pnshed  to  the  outer  side  together  with  the 
median  nerve  and  radial  vessels. 

In  Lenoir's  case  a  narrow  fragment  of  the  posterior  articular  border 
of  the  radius  had  been  broken  off;  it  remained  attached  to  the  capsule 
and  was  displaced  backward  with  the  carpus.  This  is  the  so-called 
" Barton's  fracture  of  the  radius"  (p.  332).  In  no  other  autopsy 
of  a  backward  dislocation  has  this  fracture  been  reported,  but  it  has 
been  suspected  to  exist  in  some  of  the  cases  observed  clinically,  and  a 
few  specimens  of  the  reunited  fracture  without  history  are  in  existence. 

In  a  case  quoted  in  the  Centralblatt  fur  Chirurgie,  1884,  p.  279,  })oth 
styloid  processes  were  broken. 

In  one  of  my  own  the  semilunar  bone  remained  attached  to  the 
radius,  and  the  scaphoid  was  broken.  This  attachment  of  the  semi- 
lunar was  noted  by  Couteaud,^  together  with  a  fragment  of  the  cunei- 
form.    His  paper  contains  15  cases  of  compound  backward  dislocation. 

Of  the  incomplete  form,  that  in  which  only  the  outer  portion  of  the 
carpus  is  dislocated,  the  only  case  given  in  sufficient  detail  is  that  of 
Dupuy:^  the  patient,  a  young  and  muscular  porter,  while  trying  to 
lift  a  cask  had  his  hand  forcibly  supinated  while  the  radius  remained 
pronated.  On  examination  two  hours  later  the  hand  was  found  flexed 
and  half  supinated,  while  the  radius  was  pronated.  Both  styloid  pro- 
cesses could  be  distinctly  felt,  that  of  the  ulna  in  its  normal  relations 
with  the  carpus,  but  that  of  the  radius  and  the  articular  surface  of  the 
latter  projecting  as  a  ridge  on  the  posterior  aspect  of  the  wrist.  No 
crepitus  ;  no  shortening  of  the  limb.  Reduction  was  effected  by  trac- 
tion and  direct  pressure. 

In  short,  the  dislocation  is  habitually  accompanied  by  an  extensive 
laceration  of  the  ligaments,  especially  the  anterior  and  external ;  avul- 
sion of  the  posterior  lip  of  the  articular  surface  of  the  radius  may  take 
the  place  of  rupture  of  the  posterior  ligament.  The  extensor  tendons 
are  lifted  from  their  grooves  but  not  torn  ;  the  flexors  may  be  torn  or 
pushed  to  the  outer  side  by  the  projecting  radius  ;  the  median  nerve 
and  radial  artery  have  always  escaped  injury,  even  when  the  radius 
has  been  driven  through  the  skin.  The  carpus  may  be  displaced 
directly  backward  so  as  to  rest  upon  the  posterior  surface  of  the  radius, 
without  change  in  the  relations  of  the  several  bones  that  constitute  it, 
or  with  more  or  less  separation  of  them  from  one  another,  the  semi- 
lunar bone  in  two  cases  being  completely  detached  from  the  others  and 
remaining  attached  to  the  radius ;  or  the  displacement  may  be  complete 
only  on  the  radial  side,  the  movement  being  one  of  rotation  (supina- 
tion) of  the  carpus  turning  on  its  inner  side  as  a  centre.  A  superficial 
transverse  rent  in  the  skin  on  the  palmar  surface  of  the  wrist  observed 
in  one  case  was  probably  caused  by  overstretching  of  the  skin  across 
the  projecting  end  of  the  radius. 

Symptoms.  The  deformity  bears  a  close  resemblance  to  that  of  Colles's 
fracture,  but  yet  the  differences  are  such  that  Albert  ^  says  he  was  able 
to  make  the  differential  diagnosis  at  sight.     These  differences  are  that 

»  Oouteiuid  :  Rev.  de  Cliir.,  1906,  vol.  34,  p.  193. 

2  Dupuy :   .Tourn.  de  Bordeaux,  July,  1850,  quoted  by  Tillmauns. 

*  Albert:  Chirurg.,  vol.  ii.  p.  440. 


DISLOCATIONS  AT  THE   WRIST.  7G9 

the  swelling  on  the  anterior  aspect  of  the  wrist  and  lower  part  of  the 
forearm  extends  farther  down,  nearer  to  the  hand,  in  dislocation  than 
in  fracture,  reaching  even  to  the  ball  of  the  thumb,  and  ends  more  ab- 
ruptly;  that  on  the  back  of  the  wrist  is  more  sharply  outlined  at  its  upper 
border.  In  addition,  the  hand  and  wrist  are  commonly  more  flexed  upon 
the  forearm  and  less  movable  in  dislocation,  and  may  be  adducted. 

On  palpation  the  styloid  processes  should  be  recognized,  and  their  rela- 
tions to  each  other  and  to  the  bones  of  the  hand  and  wrist  determined ; 
in  fracture  the  styloid  process  of  the  radius  is  displaced  upward  to  or 
above  the  level  of  that  of  the  ulna,  its  distance  from  the  head  of  the 
second  metacarpal  bone,  for  instance,  is  unaltered  ;  while  in  dislocation 
the  styloid  process  of  the  radius  remains  on  a  lower  level  than  that  of 
the  ulna,  and  its  distance  from  the  head  of  the  second  metacarpal  bone  is 
lessened ;  it  is  also  further  removed  anteriorly  from  the  back  of  the  wrist. 

In  some  of  the  cases  the  upper  margin  of  the  dorsal  swelling  could 
be  distinctly  felt  to  be  hard  and  rounded,  the  convexity  directed  upward 
and  the  bony  thickness  of  the  wrist  to  be  notably  increased  antero- 
posteriorly,  and  movable  upon  the  shaft  of  the  radius.  The  anterior 
swelling  is  hard  and  irregular. 

Reduction  has  usually  been  easily  effected  by  traction  upon  the  hand 
and  direct  pressure  on  the  carpus,  and  as  a  tendency  to  recurrence  is 
not  to  be  anticipated,  no  other  dressings  are  needed  than  such  as  will 
secui-e  immobility. 

In  compound  cases  the  treatment  should  be  rigorously  antiseptic, 
with  ample  provision  for  drainage.  Many  surgeons  think  that  a  par- 
tial excision  in  such  cases  favors  recovery  without  accident,  but  I  believe 
that  opinion  to  be  a  survival  from  the  pre-antiseptic  days,  and  that 
cleanliness,  drainage,  and  rest  will  make  excision  unnecessary. 

The  prognosis  is  favorable  in  the  uncomplicated  cases,  and  even 
when  the  dislocation  has  remained  unreduced  the  re-establishment  of 
the  functions  of  the  joint  has  been  satisfactory. 

Dislocations  Forward. 

The  causes  of  the  forward  dislocations  have  commonly  been  a  forci- 
ble bending  of  the  hand  forward  or  backward.  In  two  cases  it  was 
direct  violence ;  in  one  of  them,  Moore,^  the  fall  of  a  heavy  weight 
upon  the  wrist  while  the  latter  was  resting  on  the  ground  (the  account 
does  not  state  whether  the  forearm  was  resting  on  its  anterior  or  pos- 
terior surface) ;  in  the  other,  Dieu,^  the  patient  was  kicked  on  the  back 
of  the  hand  by  a  horse. 

Pathology.  Sev^en  autopsies  have  been  reported,  Malle,^  Letcnneur,' 
Collin,^  Jarjavay,*'  Boinet,"^  Goodall,^  and  Dubar."  In  addition,  there 
is  a  compound  dislocation,  for  which  Bransby  Cooper^"  amputated  ;  the 

1  Moore:  New  York  Medical  Record,  1880,  vol.  xviii.  p.  96. 

2  Dieu :  Bull,  de  la  Societe  de  Cllinlr^'ie,  1884,  p.  296. 

^  Malle:  Quoted  by  Malgaigue,  Tilliuaiiiis,  and  Servior. 

*  Letenneur:  Bull,  de  la  Societe  Anatomique,  1889,  vol.  xiv.  p.  162. 

5  Collin  :  Ihid.,  184  1,  p.  335.  «  Jarjavay  :  Ibid.,  1861,  p.  312. 

'  Boinet :  Bull,  de  la  Societe  de  Cliirurgie,  1868,  p.  211.  This  specimen  was  taken  from 
the  body  of  an  old  woman  in  the  dissecting-room  ;  possibly  the  case  was  one  of  "  spon- 
taneous "  dislocation. 

«  Goodall  :  Lancet,  1878.  vol.  i.  p.  937. 

8  Dubar  :  Gaz.  des  Hopitaux,  July  28,  1892.  '"  Cooper  :  Loc.  cit.,  p.  422. 


770  DISLOCATIONS. 

position  and  extent  of  the  wound  are  not  stated,  the  only  detail  that  is 
given  being  that  "  the  flexor  tendon  of  the  thumb  was  torn  through." 
These  autopsies  show  rupture  of  the  anterior  and  external  lateral 
ligaments,  and  sometimes  of  all,  the  carpus  being  displaced  well 
upward  along  the  anterior  aspect  of  the  radius  and  ulna ;  in  one  case, 
Goodall,  the  connection  between  the  semilunar  and  cuneiform  was 
destroyed,  the  latter  bone  retaining  its  normal  relations  with  the  trian- 
gular fibro-cartilage,  while  the  scaphoid  and  semilunar  with  the  rest 
of  the  carpus  were  displaced  forward  and  upward,  so  that  these  two 
bones  passed  over  the  free  torn  border  of  the  ligament  stretching  from 
the  styloid  process  of  the  radius  to  the  cuneiform,  which  was  thus  left 
interposed  between  them  and  the  articular  surface  of  the  radius,  and 
prevented  complete  reduction.  Apparent  reduction  was  easily  effected 
during  life,  but  the  displacement  at  once  recurred ;  there  were  other 
wounds,  and  the  patient  died  of  tetanus  on  the  eighth  day.  The  ante- 
rior lip  of  the  articular  surface  was  broken  off  in  two  cases,  and  in 
one  of  these  and  another  the  styloid  process  of  the  radius  was  broken 
oif.  Fracture  of  the  styloid  process  was  observed  clinically  by  Mal- 
gaigne,  and  fracture  of  the  anterior  lip  was  suspected  in  a  case  treated 
by  me  in  1882,  because  of  crepitus  perceived  during  reduction,  and 
because  of  the  facility  with  which  the  dislocation  could  be  reduced  and 
reproduced.  Boinet  says  that  in  producing  the  dislocation  upon  the 
cadaver  he  always  fractured  the  anterior  lip  of  the  radius. 

Symptoms.  The  hand  may  occupy  any  position  between  moderate 
dorsal  and  palmar  flexion,  the  latter  being  the  more  common,  and  the 
fingers  slightly  flexed.  Voluntary  and  passive  movements  of  the  wrist 
are  restricted  and  painful.  In  a  case  reported  by  Roland,^  a  boy  twelve 
years  old,  who  had  fallen  five  or  six  feet  and  struck  upon  the  back  of 
his  flexed  right  hand,  the  wrist  was  immovable  in  right-angled  flexion 
and  the  fingers  were  flexed  into  the  palm  and  could  not  be  straightened. 
During  the  struggles  of  etherization  the  bones  snapped  back  into  place ; 
there  was  no  tendency  to  recurrence,  and  the  boy  made  a  prompt  recov- 
ery, using  the  hand  freely  in  a  few  days.  The  deformity  consists  in  a 
marked  depression  on  the  back  of  the  wrist,  the  upper  border  of  M'hich 
is  marked  by  the  sharply  projecting  outline  of  the  radius  and  the  end 
of  the  ulna,  and  in  a  corresponding  rounded  prominence  on  the  front 
of  the  wrist,  formed  by  the  displaced  carpus.  The  hand  appears  to  be 
shortened  at  the  expense  of  the  wrist,  and  an  actual  shortening  can  be 
demonstrated  by  measurement  from  the  styloid  process  of  the  radius 
to  the  finger.     The  antero-posterior  diameter  of  the  wrist  is  increased. 

In  the  old  cases  (Collin,  Jarjavay,  Boinet)  a  new  articular  surface 
had  formed  on  the  anterior  surface  of  the  radius  and  ulna,  in  two  of 
the  cases  a  full  inch  above  their  lower  ends.  In  Collin's  the  limb  was 
equal  in  strength  and  freedom  of  use  to  the  other,  and  all  the  move- 
ments were  complete  except  those  of  abduction  and  adduction  of  the 
wrist,  in  which  there  was  slight  and  greater  loss  respectively. 

Reduction  has  been  easily  effected,  with  or  without  anaesthesia,  by 
traction  upon  the  hand  or  by  direct  pressure  on  the  displaced  bones  or 
by  a  combination  of  the  two.  In  my  case  slight  displacement  forward 
persisted. 

'  Eoland  :  Philadelphia  Medical  Times,  1879,  vol.  ix.  p.  430, 


DISLOCATIONS  AT  THE   WRIST.  771 

Dislocations  Outward. 

Of  this  form  of  dislocation  only  one  case  has  been  reported,  by 
Chapplain/  of  Marseilles.  The  patient  was  a  man,  forty-seven  years 
old,  who  had  fallen  from  a  height  of  four  metres,  the  weight  of  his 
body  being  received  upon  his  left  hand.  The  hand  was  widely  dis- 
placed to  the  outer  side,  and  through  a  wound  situated  upon  the  inner 
side  of  the  wrist  the  bones  of  the  forearm  projected  and  exposed  their 
entire  articular  surface.  The  wound  of  the  skin  extended  from  the 
junction  of  the  posterior  and  internal  surfaces  of  the  wrist,  around 
the  latter,  and  half-way  across  the  anterior  surface.  The  styloid  pro- 
cess of  the  radius  had  been  broken  off,  and  it  accompanied  the  carpus 
in  its  displacement.  The  pisiform  was  almost  completely  detached 
and  crushed ;  the  connections  of  the  semilunar  with  the  carpal  bones 
had  been  ruptured,  and  it  preserved  its  relations  with  the  radius.  There 
was,  in  addition,  a  dislocation  of  the  elbow  backward. 

The  fragments  of  the  pisiform,  the  styloid  process  of  the  radius,  and 
the  semilunar  were  removed,  and  the  dislocation  easily  reduced.  A 
single  suture  was  placed  at  the  centre  of  the  wound,  and  the  hand  and 
forearm  were  thickly  enveloped  in  cotton  firmly  bound  on  (Guerin's 
dressing).  A  second  dressing  was  applied  on  the  eleventh  day  and 
removed  on  the  twenty-second,  when  a  large  abscess  was  found  on  the 
back  of  the  hand  and  forearm,  and  the  wound  made  at  the  time  of 
the  accident  nearly  healed.  A  subsequent  note,  five  and  a  half  months 
after  the  injury  was  received,  states  that  the  wounds  were  all  healed, 
the  phalangeal  and  metacarpo-phalangeal  joints  had  almost  entirely 
regained  their  mobility,  the  wrist  was  completely  anchylosed,  and  the 
elbow  only  slightly  movable. 

Pathological  Dislocations  of  the  Radio-carpal  Joint. 

These  dislocations,  so  far  as  they  are  due  to  destructive  disease  of 
the  joint,  are  of  secondary  interest,  and  do  not  readily  lend  themselves 
to  a  general  description.  Malgaigne  quotes  a  few  cases,  genei^ally 
reported  briefly,  of  dislocations  forward  that  have  been  slowly  pro- 
duced in  consequence  of  hydrarthrosis,  arthritis,  permanent  contraction 
of  the  flexor  muscles,  and  the  retraction  of  cicatricial  bands ;  he  refers 
also  to  two  cases  briefly  mentioned  by  Guerin  among  his  congenital 
dislocations,  one  in  a  child  of  six  years,  and  the  other  in  a  girl  of 
fourteen  years  with  incomplete  paralysis  of  the  muscles  of  the  fore- 
arm, in  which  the  dislocation  was  backward  and  upward  and  backward 
and  outward  respectively.  A  more  common  form,  one  that  has  been 
seen  with  sufficient  frequency  to  have  received  special  study,  is  the 
following : 

Spontaneous  Subluxation  Forward. 

This  affection  was  first  described  by  Dupuytren  ^  as  a  condition  of 
the  joint  which  might  be  mistaken  for  a  dislocation,  and  of  which  he 

1  Chapplain  :  Bull,  de  la  Societc  de  Chinirjiie,  1874,  \i.  47y. 
^  Dupuytren  :  Clinique  Chirurgicale,  vol.  iv.  p.  209. 


772  BISLOCA  TIONS. 

had  seen  a  considerable  number  of  cases,  especially  in  men  whose 
occupations  compelled  them  to  make  repeated,  sudden,  and  violent 
traction  with  their  hands,  as  in  working  a  press  or  dressing  cloth.  He 
said  that  under  the  influence  of  these  efforts  the  ligaments  of  the  joint 
became  stretched  so  that  the  bones  were  capable  of  more  extensive 
change  of  place  than  was  normal ;  the  carpus,  being  no  longer  held 
firmly  against  the  bones  of  the  forearm,  yielded  to  the  traction  of  the 
flexor  muscles  and  shifted  to  a  position  in  front  of  their  lower  ends. 
All  the  signs  of  a  dislocation  were  present  except  pain  and  inflamma- 
tion. The  more  or  less  considerable  deformity  and  weakness  were  the 
only  inconveniences  of  the  condition,  and  were  not  sufficient  to  cause 
the  patients  to  intermit  their  work  or  seek  medical  help.  Ordinarily 
the  deformity  could  be  reduced  by  traction,  but  it  recurred  as  soon  as 
the  parts  were  left  at  rest. 

Malgaigne,  referring  to  this  description,  says  that  he  had  for  twenty 
years  vainly  sought  an  example  of  the  condition  in  the  largest  press- 
rooms of  Paris,  and  had  met  with  only  one,  in  a  patient  thirty-six 
years  old,  in  whom  the  condition  developed  at  about  the  age  of  twelve 
years  apparently  as  the  result  of  carrying  heavy  burdens ;  in  this  case 
the  carpus  was  displaced  forward  and  upward,  three  centimetres  above 
the  lower  end  of  the  ulna,  and  one  centimetre  above  that  of  the  radius, 
the  antero-posterior  diameter  of  the  wrist  was  five  and  a  half  centi- 
metres on  the  ulnar  side,  but  could  be  reduced  to  four  and  a  half  cen- 
timetres by  pressure,  on  the  radial  side  it  was  only  four  centimetres, 
but  the  articular  edge  of  the  radius  [posterior?]  was  much  depressed 
and  apparently  inclined  forward.  Above  the  carpus,  on  the  anterior 
surface  of  the  radius,  and  apparently  adherent  to  it,  was  a  bony  promi- 
nence. All  movements  were  free,  except  dorsal  flexion,  which  was 
notably  diminished. 

In  1878  Madelung^  read  before  the  Seventh  Congress  of  German 
Surgeons  a  paper  upon  the  subject  based  upon  the  observation  of 
twelve  cases  and  the  post-mortem  examination  of  one.  Of  his  twelve 
patients  the  dislocation  was  unilateral  in  ten  (four  on  the  right  side, 
five  on  the  left,  and  in  one  the  side  was  not  noted),  and  bilateral  in 
two;  eight  patients  were  females,  four  males.  The  earliest  age  at 
which  the  condition  originated  was  the  thirteenth  year;  in  only  two 
cases  did  it  begin  after  the  twenty-third  year.  All  but  one  of  the 
patients  belonged  to  the  working  class,  but  their  occupations  were  not 
marked  by  great  muscular  eflbrts.  The  spe-cimen  was  obtained  from 
the  body  of  a  woman  about  twenty  years  old.  The  appearance  of  the 
limb  was  so  typical  that  he  was  convinced  of  the  correctness  of  the 
diagnosis  of  spontaneous  subluxation,  even  in  the  absence  of  any  history 
of  the  case.  There  was  no  sign  of  chronic  inflammation  of  the  bones  of 
the  arm  or  of  any  part  of  the  skeleton.  The  limb  was  frozen  and  then 
sawn  longitudinally  in  two  places.  The  first  section  was  made  through 
the  centre  of  the  os  magnum  and  its  articulation  with  the  semilunar, 
and  divided  the  end  of  the  radius  so  near  its  ulnar  border  that  a  por- 

1  Madelung :  Deutsche  Gesellschaft  fiir  Chirurgie,  1878,  p.  259,  and  Archiv  fiir 
klinische  Chirurgie,  1879,  vol.  xxiii.  p.  395.  See  also  Abadie,  Re^iie  d'  Orthopedic, 
1903,  No.  6.  Benneke,  Beilage  zum  Centralblatt  fiir  Chir.,  1904,  p.  157.  Miiller:  Ztl- 
blatt  fiir  Chir.,  1907,  p.  1333.    Franke :  Deutsche  Ztscht.  fiir  Chir.,  vol.  xcii.  p.  156. 


DISLOCATIONS  AT  THE    WRIST. 


773 


tion  of  the  incisura  semilunaris  shows  in  the  section.  The  second  sec- 
tion divides  the  lower  part  of  the  ulna  into  two  equal  parts  and  passes 
through  the  cuneiform,  pisiform,  and  unciform  bones.  The  sections 
show  that  the  radial  side  of  the  carpus  is  displaced  about  half  an  inch 
forward  and  an  equal  distance  upward  by  the  absorption  of  the  anterior 
half  of  the  lower  end  of  the  radius,  the  posterior  half  persisting  like 
a  malleolus  extended  over  the  dorsum  of  the  wrist,  and  the  displace- 
ment forward  of  the  ulnar  side  of  the  carpus  is  much  more  marked. 
In  Benneke's  case  the  a;-rays  showed  a  similar  condition. 

Fig.  433. 


Madelung's  case  of  spontaneous  dislocation  of  the  carpus  forward  :  longitudinal  section 
through  (C)  the  os  magnum  and  (L)  the  semilunar. 

Fig.  4.34. 


The  same:  longitudinal  section  through  the  ulna,  (H)  the  unciform,  and  (T)  the  cuneiform. 

It  seems  probable  that  a  case  reported  by  Jean^  as  a  double  congen- 
ital dislocation  forward  was  of  this  character.  On  the  right  side  the 
cuneiform  was  placed  well  in  front  of  the  ulna ;  the  semilunar  and 
scaphoid  not  so  far  in  front  of  the  radius,  which  liad  formed  a  new 
articular  surface  by  loss  of  its  anterior  lip.  In  the  left  wrist  the  dis- 
placement was  of  the  sarhe  character  but  less  marked.  Possibly,  also, 
Boinet's  case,  quoted  above,  page  769,  and  R.  W.  Smith's  case^  of  sup- 
posed congenital  dislocation  belong  to  this  class,  and  also  one  observed 
clinically  and  reported  by  Pooley'^  as  a  double  congenital  dislocation 
forward. 


'  .Jean  :  Bull,  de  la  Socictc  Anatomique,  1875,  p.  398. 

2  R.  W.  Smith :  Loc.  cit.,  p.  251. 

'  Pooley :  American  Practitioner,  18S0,  vol.  xxi.  p.  21(5. 


53 


774  DISLOCATIONS. 

The  production  of  the  deformity  in  the  cases  observed  clinically  was 
always  gradual,  requiring  from  six  months  to  two  years  for  its  full 
development,  and  in  no  case  could  it  be  attributed  to  a  traumatism, 
either  slight  or  severe,  and  in  no  case  were  there  any  signs  of  acute  or 
chronic  inflammation  of  any  part  of  the  joint.  In  most  cases  the 
patients  attributed  it  to  continuous  hard  labor  with  the  hands,  but  it  did 
not  appear  that  this  labor  was  more  than  usually  prolonged  or  hard. 
The  women  usually  attributed  it  to  washing  clothes ;  two  of  the  men 
were  farmers,  one  a  tanner,  and  one  a  shoemaker.  In  the  discussion 
that  followed  the  reading  of  the  paper  Hirschberg  said  he  had  seen 
two  clearly  marked  cases,  the  result  of  practice  at  the  piano.  The 
deformity  in  all  the  cases  was  accompanied  by  pain  in  the  joint  and 
was  marked  especially  by  the  increasing  prominence  of  the  end  of  the 
ulna.  After  a  time  the  pain  ceased,  the  deformity  remained  stationary, 
and  the  freedom  of  use  of  the  limb  was  unimpaired  except  by  diminu- 
tion or  total  loss  of  dorsal  flexion. 

After  Madelung's  attention  had  been  called  to  the  subject  by  obser- 
vation of  his  earlier  cases,  he  took  pains  critically  to  examine  the  w^rists 
of  people  in  all  classes  of  society,  and  was  astonished  to  find  how  fre- 
quently he  encountered  slight  deviations  from  the  normal  shape,  all  of 
which  were  of  the  type  of  spontaneous  dislocation  forward  and  were 
characterized  not  only  by  the  abnormal  projection  of  the  end  of  the 
ulna  but  also  by  change  in  the  articular  surface  of  the  radius  and 
the  position  of  the  carpus.  He  attributed  the  more  notable  changes 
in  the  end  of  the  radius  found  in  the  fully  developed  cases  to  the 
arrest  of  the  growth  of  its  anterior  portion  and  to  the  overgrowth  of 
its  posterior  portion  stimulated  by  the  loss  of  the  opposing  pressure 
normally  exerted  by  the  carpus,  and  he  sees  an  analogy  between  this 
change  and  those  observed  in  pes  valgus  and  genu  valgum.  I  have 
seen  one  case,  a  young  lady  who  spent  much  time  at  the  piano.  Other 
cases  have  been  recently  reported  by  Schulze,^  Sauer,^  3  cases,  Schade/ 
Putti,*  and  Stokes.^ 

Estor,^  who  collected  85  cases,  inclines  to  the  theory  of  gradual  de- 
velopment upon  a  congenital  peculiarity,  probably  laxity  of  the  lower 
radio-ulnar  joint ;  in  36  of  his  85  cases  the  condition  was  observed  in 
more  than  one  member  of  a  family,  and  in  70  both  wrists  were  affected. 
Siegrist''  renews  the  rachitic  theory  of  its  origin. 

A  reversed  form  has  been  described  by  Kirmisson  *  and  by  Stetten,'* 
2  cases. 

Symptoms.  The  most  marked  deformity  is  seen  when  the  limb  is 
viewed  in  profile  from  the  ulnar  side ;  the  end  of  the  ulna  projects- 
markedly  at  the  back  of  the  wrist ;  the  hand  is  displaced  toward  the 
palmar  side,  and  the  antero-posterior  diameter  of  the  wrist  is  greatly 

1  Schulze:  Miinch.  med.  Wocbenschrift,  1905,  No.  30.     • 

2  Sauef  :   Beitrage  zur  klin.  Chir.,  vol.  xlviii.  part  4. 

3  Schade :  Ztlblatt  fiir  Chir.,  1906,  p.  811. 
*  Putti:  Ibid.,  p.  1011. 

5  Stokes  :  Annals  of  Surg.,  Aug.,  1910. 

6  Estor :  Revue  de  Chir.,  xxvii.  Nos.  8  and  9. 

'  Siegrist :  Deutsche  Ztschft.  fiir  Chir.,  vol.  xcl.  p.  524. 

8  Kirmisson  :  Les  difformites  acquises  de  I'appareii  iocomoteur^  Paris,  1902. 

9  Stelten  :  Ztlblatt  fiir  Chir.,  1908,  p.  949.      - 


DISLOCATIONS  AT  THE    WRIST.  775 

increased.  Seen  from  the  radial  side  tlie  displacement  forward  does 
not  appear  so  great,  and  the  depression  below  the  end  of  the  radius  is 
bridged  over  by  the  extensor  tendons ;  if  these  tendons  are  relaxed  by- 
dorsal  flexion  of  the  hand  the  posterior  part  of  the  articular  surface  of 
the  radius  can  be  traced  with  the  finger,  and  its  edge  can  be  felt  to  be 
rounder  than  usual.  In  addition,  the  entire  epiphysis  appears  to  be 
bent  forward. 

By  traction  and  pressure  the  carpus  can  be  brought  nearer  to  the 
ulna,  but  it  returns  at  once  to  its  former  place  when  the  pressure  is 
removed.  No  change  can  be  effected  in  the  relations  of  the  carpus 
and  radius. 

Sometimes  the  region  is  very  painful ;  points  that  are  tender  on 
pressure  are  seldom  found,  and  usually  only  at  the  upper  margin  of 
the  joint.  Every  movement  of  the  joint,  especially  dorsal  flexion,  is 
very  painful. 

Activ^e  and  passive  dorsal  flexion  is  limited  to  an  extent  that  corre- 
sponds to  the  degree  of  the  subluxation,  and  in  the  most  marked  cases 
the  hand  cannot  be  carried  backward  beyond  straight  extension.  The 
range  of  palmar  flexion  is  more  often  increased  than  diminished,  unless 
pain  is  present. 

Treatment.  The  alteration  in  the  shape  of  the  bones  fully  explains 
the  failure  of  the  few  attempts  that  have  been  made  forcibly  to  reduce 
the  displacement,  and  the  fact  that  the  limb  recovers  nearly  its  full 
usefulness  after  the  growth  of  the  skeleton  ceases  and  the  progress  of 
the  displacement  is  arrested,  furnishes  a  sound  reason  against  operative 
interference.  Prolonged  attempts  made  by  Madelung  to  improve  the 
position  by  fixation  in  gypsum  dressings  and  methodical  manipulations 
did  no  good  beyond  relief  of  pain,  and  after  he  had  learned  the  pathol- 
ogy and  nature  of  the  affection  he  limited  his  treatment  to  efforts  to 
increase  the  strength  of  the  arm  in  all  its  parts  by  methodical  use  and, 
in  some  cases,  to  the  wearing  of  a  moulded  leather  bracelet  which  could 
be  tightened  or  loosened  and  was  kept  in  place  by  a  loop  passing 
between  the  thumb  and  index-finger ;  this  prevented  movements  of 
the  wrist  and  left  the  fingers  free.  In  extreme  cases  osteotomy  of  the 
radius  has  been  proposed. 

Congenital  Dislocations  of  the  Radio-carpal  Joint. 

The  question  of  congenital  dislocation  of  the  wrist  is  extremely  diffi- 
cult and  obscure,  for  in  the  great  majority  of  the  reported  cases  the 
history  is  so  defective  that  the  period  at  which  the  displacement  took 
place  must  remain  uncertain,  although  in  most  of  them  it  was  certainly 
during  infancy  or  early  childhood.  In  some  the  congenital  origin  of 
the  malforniation  can  hardly  be  called  in  (juestion,  because  it  is  marked 
by  great  irregularities  of  shape  and  develo])ment  extending  over  sev- 
eral bones  and  joints,  but  the  propriety  of  classifying  such  cases  as 
dislocations  may  well  be  questioned,  for  not  only  do  the  joint  surfaces 
present  hardly  a  trace  of  their  normal  form,  but  also  one  or  more  of 
the  constituent  bones  may  be  entirely  lacking.  Such  cases  seem  much 
more  properly  to   belong  among  the  "congenital  malformations"  and 


776  DISLOCATIONS. 

to  require  classification  as  "  club-hands "  rather  than  as  dislocations. 
In  most  of  the  reported  cases  in  which  the  deformity  has  involved  only 
the  wrist  the  theory  of  congenital  origin  has  been  based  upon  the 
absence  of  the  history  of  any  traumatism  that  could  account  for  the 
deformity,  upon  the  statements  of  the  patient  or  his  friends  that  it  had 
existed  as  long  as  they  could  remember,  and  upon  its  symmetrical 
occurrence  in  both  wrists.  The  history  of  spontaneous  dislocations 
forward  shows  how  defective  this  argument  is. 

The  only  alleged  example  of  congenital  dislocation  which  is  accepted 
as  such  by  Bouvier^  and  Malgaigne  is  one  reported  by  Marigues  in 
1755;  it  was  observed  in  a  stillborn  child.  The  radius  was  widely 
separated  from  the  ulna  at  its  lower  end,  and  in  the  interval  between 
them  were  lodged  the  bones  of  the  first  row  of  the  carpus  which  were 
held  in  place  by  strong  ligaments  ;  the  hand  was  hooked  inward,  and 
it  was  held  in  this  position  especially  by  a  strong  ligament  which 
extended  from  the  second  row  of  the  carpus  to  the  end  of  the  radius. 

R.  W.  Smith  ^  describes  in  detail  several  specimens  of  displacement 
and  deformity  which  he  deemed  of  congenital  origin,  and  quotes  a 
well-known  case  reported  by  Cruveilhier  in  the  ninth  livraison  of  his 
Anatomie  Pathologique.  One  of  these  cases  and  two  or  three  others 
which  have  also  been  reported  as  congenital  have  been  mentioned  in 
the  preceding  section. 

DISLOCATIONS  OF  THE  CARPAL  BONES. 

These  present  themselves  as  isolated  dislocations  of  the  individual 
bones  or  as  partial  or  incomplete  dislocations  of  the  medio-carpal  joint. 

Of  the  eight  bones  which  form  the  carpus  only  the  pisiform  on  the 
ulnar  side  and  the  trapezium  on  the  radial  side  can  be  distinctly  pal- 
pated. The  former  is  felt  as  a  small,  hard  lump  at  the  junction  of  the 
palm  and  wrist  close  below  the  inner  end  of  the  lowest  of  the  transverse 
creases  that  cross  the  wrist ;  it  rests  upon  the  anterior  face  of  the  cunei- 
form bone.  The  trapezium  can  be  readily  grasped  between  the  thumb 
and  finger  just  above  the  base  of  the  first  metacarpal  bone.  A  line 
drawn  straight  across  the  back  of  the  wrist  from  one  end  to  the  other 
of  the  lowest  transverse  crease  on  the  palmar  surface  crosses  the  neck 
of  the  OS  magnum  directly  above  the  base  of  the  third  metacarpal  when 
the  hand  is  extended  in  line  with  the  forearm,  and  the  finger  can  feel 
a  distinct  depression  at  this  point,  the  upper  margin  of  which  is  formed 
by  the  lower  face  of  the  semilunar ;  if  now  the  wrist  is  flexed  forward 
the  hollow  becomes  filled  by  a  projecting  piece  of  bone,  the  head  of  the 
OS  magnum.  The  medio-carpal  joint  is  that  between  the  three  bones 
of  the  first  row  above  and  the  four  bones  of  the  second  row  below. 

1  Bouvier :  Diet.  Enclycopcdique  des  Sc.  Med.,  art.  Main  Bote,  p.  166. 
'  E.  W.  Smith  :  Fractures  and  Dislocations,  1847,  p.  238. 


DISLOCATIOyS  AT  THE   WRIST.  777 

Medio-carpal  Dislocations. 

Of  these,  one  dislocation  backward,  verified  by  autopsy,  and  two 
forward,  observed  clinically,  have  been  reported.  It  is  evident  that  it 
may  be  difficult  to  distinguish  clinically  between  this  and  some  classed 
as  radio-carpal  dislocations  or  as  midcarpal  fracture-dislocations. 

A  backward  dislocation  was  reported  by  Maisonneuve '  in  a  ]iatient 
who  had  fallen  from  a  height  of  forty  feet.  The  hand,  displaced  bodily 
to  a  plane  posterior  to  that  of  the  forearm,  was  shortened  several  lines  ; 
behind,  a  few  lines  below  the  styloid  processes,  was  a  transverse  bony 
prominence  more  than  a  centimetre  high,  with  a  depression  below, 
opposite  the  transverse  fold  of  the  wrist.  The  fingers  were  flexed,  and 
a  considerable  eifort  was  required  to  extend  them.  The  bones  of  the 
second  row  were  completely  separated  from  those  of  the  first,  and  over- 
rode them  posteriorly  more  than  a  centimetre.  A  small  piece  of  the 
scaphoid  remained  attached  to  the  trapezium,  and  a  portion  of  the 
cuneiform,  with  the  pisiform,  accompanied  the  unciform.  The  internal 
and  external  lateral  ligaments  of  the  radio-carpal  joint  were  com])letely 
ruptured,  as  were  also  the  anterior  and  posterior  ligaments  uniting  the 
two  rows  of  the  carpus. 

An  incomplete  dislocation  forward  was  reported  by  Despres.  ^  The 
patient  was  presented  wnth  his  deformity  to  the  Societe  de  Chirurgie, 
and  as  there  was  a  difference  of  opinion  concerning  the  nature  of  the 
lesion  a  committee  was  appointed  to  examine  and  report  upon  it ;  they 
unanimously  confirmed  the  diagnosis.  The  patient  was  a  man  twenty 
years  old  ;  the  injury  was  caused  by  a  fall  from  a  swing,  probably  upon 
the  back,  the  hand  being  caught  between  the  body  and  the  ground. 
\¥hen  he  came  to  the  hospital,  a  week  later,  there  was  no  swelling  or 
redness  of  the  region  ;  on  the  back  of  the  wrist,  a  finger-breadth  below 
the  edge  of  the  radius,  was  a  depression  below  which  the  wrist  and 
hand  had  their  normal  appearance,  and  above  which,  between  it  and 
the  radius,  the  finger  recognized  a  distinct  bony  resistance.  The  axis 
of  the  hand  was  deviated  outward.  On  the  palmar  surface  the  tendon 
of  the  palmaris  longus  and  the  thenar  and  hypothenar  eminences  were 
prominent.  All  the  movements  of  the  wrist  were  preserved,  and  only 
forced  flexion  was  painful.  Forced  extension  increased  the  displacement 
without  notably  changing  the  form  of  the  palmar  surface  of  the  wrist. 
During  flexion  the  prominence  of  the  head  of  the  os  magnum  was  less 
apparent  than  in  the  other  wrist;  the  movement  reduced  the  dislocation. 

The  treatment  consisted  in  maintaining  the  hand  in  the  flexed  posi- 
tion in  which  the  bone  returned  to  its  place  by  means  of  a  spica  ban- 
dage;  it  was  begun  eleven  days  after  the  accident,  and  by  the  fourth 
day  the  pain  had  disappeared  and  the  wrist  had  regained  its  form  and 
functions.     The  bandage  was  worn  a  week  longer. 

A  complete  dislocation  forward  has  been  reported  by  Richmond  ;  *  the 
patient  was  a  man,  forty-seven  years  old,  who  fell  upon  his  hand  from 
a  height  of  about  nine  feet.      The  hand,  fivmi  tlic  wrist  to  tlic  l-ciiuckles, 

1  Maisonneuve  :  Mem.  de  la  Soc.  de  Chir. ,  quoted  by  Malgaigne. 
2Despr6s:  Bull,  de  la  Soc.  de  Chirure^ie,  1875,  vol.  i.  p.  412. 
3 Richmond:  Lancet,  1879,  vol.  i.  p.  844. 


778  DISLOCATIONS. 

was  very  noticeably  shortened ;  there  was  a  prominent  transverse  ridge 
on  the  back  of  the  wrist  below  the  ends  of  the  radius  and  ulna,  and 
below  this  ridge  was  a  marked  depression.  On  the  palmar  aspect  the 
base  of  the  hand  was  unduly  prominent,  the  general  direction  of  the 
metacarpal  bones  being  quite  altered  by  their  bases  being  pushed  for- 
ward toward  the  palm.  Voluntary  flexion  and  extension  were  lost. 
The  ends  of  the  radius  and  ulna  seemed  separated  somewhat  from  each 
other  ;  the  transverse  dorsal  ridge  could  be  demonstrated  to  be  the  first 
row  of  carpal  bones  with  the  semilunar  unduly  prominent ;  between  it 
and  the  radius  and  ulna  flexion  and  extension,  although  restricted, 
could  be  obtained  with  considerable  ease  and  without  crepitus.  None 
of  the  carpo-metacarpal  joints  had  sustained  any  injury.  On  the  pal- 
mar prominence  the  trapezoid  could  be  felt  placed  more  anteriorly  than, 
and  considerably  above,  the  level  of  the  trapezium  ;  and  nearer  the 
ulnar  side  the  head  of  the  os  magnum  could  be  felt  slightly  overlapping 
the  ends  of  the  radius  and  ulna,  which  on  the  palmar  surface  were 
quite  obscured;  and  on  flexion  and  extension  of  the  hand  the  os  mag- 
num could  be  felt  to  ride  on  their  anterior  surface.  The  displacement 
of  the  unciform,  although  distinct,  was  much  less  marked. 

Midcarpal  Fracture-dislocation.^ 

Under  this  title  is  described  an  injury  of  which  the  typical  features 
are  fracture  of  the  scaphoid,  dislocation  forward  of  the  semilunar  and 
the  proximal  fragment  of  the  scaphoid,  and  more  or  less  derangement 
of  the  relations  of  the  os  magnum  with  the  adjoining  bones.  De  Quervain 
termed  it  "Dislocation-fracture  of  the  Carpal  Bones"  or  "of  the  inter- 
carpal joint,"  and  Delbet  "  Dislocation  of  the  Os  Magnum,"  with  sub- 
titles indicating  variations.  The  title  at  the  head  of  this  section  seems 
to  me  to  be  preferable  to  either  and  is  practically  the  same  as  that  used 
by  Schoch. 

The  first  known  example  was  found  by  Fugue  ^  at  autopsy  in  1887  ; 
then  ten  years  later  a  few  cases  were  disclosed  by  the  arrays,  and  in 
1 901  De  Quervain,  having  treated  a  case  in  which  both  wrists  were 
similarly  injured,  was  led  by  the  identical  features  of  the  two  lesions 
to  suspect  that  they  might  represent  a  class  and  to  study  the  subject 
with  the  aid  of  such  cases  as  he  could  find  reported.  Since  then  mauv 
cases  have  been  reported,  especially  from  the  Zander  institutes,  and  two 
papers  dealing  with  the  subject  in  great  detail  have  been  published  by 
Schoch  and  Delbet.  The  former  contains  a  large  bibliography,  and  the 
latter  the  results  of  much  experimentation. 

The  injury,  while  infrequent,  is  not  rare.  It  occurs  almost  exclus- 
ively in  males,  doubtless  because  of  their  greater  exposure  to  accidents, 
and  between  the  ages  of  twenty  and  forty  years.     The  common  cause  is 

1  De  Quervain  :  Monatschrift  fur  Unfallheilkunde,  1902,  vol.  ix.  p.  65.  WolfT:  Ibid, 
vol.  X.  Schoch :  Beitrage  zur  klin.  Chirurgle,  1907-8,  vol.  xci.  p.  53.  Delbet :  Bull,  et 
Mem.  de  la  Soc.  de  Chirurgie,  1908,  vol.  xxxiv.  p.  377.  Lilienfeld :  Zeitschrift  fiir 
Orthop.  Chir.,  1908.  vol.  xx.  p.  437.  See  also  several  of  the  later  references  given  in 
the  bibliography  of  Fractures  of  the  Carpal  Bones  and  Dislocation  of  the  Semilunar. 

^  Gaz.  hebdom.  de  Montpellier,  1887,  vol.  ix.  No.  1. 


PLATE  XXXI 


Mi  dear  pal   Fiactu  re-dislocation. 


PLATE  XXXII 


Midcarpal  Fracture-dislocation  by  Volar  Flexion. 


PLATE  XXXIII 


Midcarpal  Fracture-dislocation.       Sanie  case  as  Plate  XXXI. 


PLATE  XXXIV 


Mi  dear  pal   Fracture-dislocation. 


PLATE  XXXV 


Midcarpal  Fracture-dislocation,  after  Removal  of  Proximal 
Fr-agi-nent  of  Scaphoid. 


PLATE  XXXVI 


54 


Mi  clear  pal    Fr'aclur-e-dislocation. 


DISLOCATIONS  AT  THE    WRIST.  779 

violence  received  on  the  ball  of  the  dorsally-flexed  hand  in  a  fall.  In 
three  or  four  cases  (one  ray  o\vn,  Plates  XXXII  and  XXXIII)  the  cause 
appeared  to  be  forced  volar  flexion.  In  circumstances  so  different  the 
mechanism  cannot  be  the  same,  but  in  the  common  form,  dorsal  flexion, 
the  dislocating  pressure  appears  to  be  applied  through  the  head  of  the 
OS  magnum  to  the  semilunar.  The  volar  ligament  connecting  the 
semilunar  and  os  magnum  yields  while  that  connecting  the  anterior  lip 
of  the  radius  and  the  semilunar  remains  untom  ;  the  semilunar  slips 
forward,  with  rotation  about  its  transverse  axis,  and  takes  with  it  the 
proximal  portion  of  the  scaphoid  (See  also  Chapter  XXI.,  Fractures  of 
the  Carpal  Bones).  The  semilunar  may  even  pass  upward,  above  the 
edge  of  the  radius.  In  only  one  reported  case  (Sulzberger)  has  the 
cuneiform  accompanied  the  semilunar.  The  regularity  of  this  separa- 
tion of  the  semilunar  and  adjoining  portion  of  the  scaphoid,  and  its 
occurrence  under  different  forms  of  violence  suggests  an  anatomical  or 
anatomo-mechanical  structure  of  the  carpus  favoring  it  which  is  further 
supported  by  an  interesting  observation  which  I  reported  in  1891  to 
the  New  York  Surgical  Society,  the  same  pieces  were  separated  from 
th(>  carpus  but  remained  attached  to  the  radius,  the  rest  of  the  carpus 
being  dislocated  from  them  and  it ;  several  similar  cases  have  been  re- 
ported. Schoch  thinks  that  the  cuneiform  and  the  distal  portion  of 
the  scaphoid  may  be  considered  as  portions  of  the  second  row  of  carpal 
bones  rather  than  of  the  first  because  of  their  stronger  ligamentous  at- 
tachments to  it.     (See  also  page  768.) 

Delbet's  experiments  showed  that  when  the  injury  was  produced  by 
extreme  dorsal  flexion  fracture  of  the  scaphoid  was  the  first  to  occur, 
and  that  if  the  movement  was  then  arrested  the  volar  ligaments  were 
found  untorn.  He  found  also  that  if  the  movement  was  continued  a 
little  further  the  head  of  the  os  magnum  stripped  the  dorsal  ligament 
from  the  posterior  pole  of  the  semilunar,  and  that  if  the  movement  was 
then  arrested  the  head  of  the  os  magnum  would  rest  in  dorsal  dislo- 
cation upon  the  back  of  the  semilunar,  whence  it  could  be  easily  re- 
placed again,  leaving  only  the  fracture  of  the  scaphoid  to  be  recognized 
clinically.  This  is  apparently  one  of  his  reasons  for  including  isolated 
fracture  of  the  scaphoid  in  the  larger  group. 

Additional  force  pressing  the  carpus  directly  or  ol)liquely  toward 
the  radius  and  forcing  the  semilunar  forward  from  its  place  is  necessary 
to  the  production  of  the  typical  complete  form. 

The  semilunar  and  proximal  fragment  having  been  displaced  forward 
from  the  radius,  the  head  of  the  os  magnum  passes  into  the  gaj)  thus 
created  and  approaches  the  inferior  surface  of  the  radius. 

According  as  the  semilunar  is  displaced  more  or  less  forward,  the 
OS  magnum  is  in  line  with  the  radius  or  disi)la('C(l  backward  from  it. 
The  different  positions  of  these  bones  are  shown  in  the  series  of  ])lat('S 
(XXXI-XXXYI). 

Three  associated  lesions  occni-  fr('(|uciitly  ciiongli  to  be  deemed  ex- 
treme additions  to  the  type  :  fracture  of  tiie  styloid  processes  of  the  radius 


780 


DISLOCATIONS. 


and  ulna,  and  Colles's  fracture.  Others — fracture  of  the  cuneiform  and 
of  the  OS  magnum,  and  mutual  crushing  of  the  os  magnum  and  unci- 
form— ^probably  depend  upon  variations  in  the  degree  and  continuation  of 
the  force.  So  also  with  such  cases  as  mine  of  1891,  above  mentioned,  and 
one  or  two  similar  ones  in  which  the  end  of  the  radius  projected  through 
the  skin,  in  which  the  semilunar  and  fragment  of  the  scaphoid  preserved 
their  relations  with  the  radius,  the  direction  of  the  violence  was  up- 
ward and  backward  instead  of  upward  and  forward.  Also  fracture  of 
the  palmar  or  dorsal  edge  of  the  articular  surface  of  the  radins  has 
been  seen. 

The  symptoms  are  fairly  characteristic.      Function  is  lost  because  of 
pain  ;  the  fingers  are  flexed  and  an  attempt  to  straighten  them  causes  pain 

Fig.  435. 


Midcarpal  fracture-dislocation.    «i,  semilunar.     S' S,"   broken  scaphoid      Styloid 
cess  ot  radius  broken.    Tracing  from  steroscopic  skiagram.    The  shudin-  renrpse^t^ 


ttie  deeper  ( dcrsal)  levels.    (Schoch  ) 


shading  represents 


because  of  pressure  of  the  tendons  on  the  displaced  and  broken  bones 
and  on  the  median  nerve.  The  hand  is  slightly  shifted  to  the  radial 
side,  and  the  end  of  the  ulna  is  consequently  prominent.  The  wrist  is 
slightly  shortened  by  the  approximation  of  the  os  magnum  to  the  radius, 
and  its  antero-posterior  diameter  is  increased  by  the  dislocation  forward 
of  the  semilunar  and  fragment  of  the  scaphoid",  which  can  be  felt  as  a 
hard,  perhaps  movable,  prominence  or  as  increased  resistance  beneath 
the  flexor  tendons.     The  broad,  thick  extensor  tendons  interfere  with 


DISLOCATIONS  AT  THE    WRIST. 


781 


palpation  of  the  dorsum  but  sometimes  a  gap  can  be  felt  below  the  dorsal 
edge  of  the  radius.  The  hand  may  be  abnormally  movable  in  both 
planes  upon  the  forearm. 

The  differential  diagnosis  from  the  commoner  injuries  of  the  regie tu — 
sprain,  Colles's  fracture,  and  fracture  of  the  scaphoid — should  not  be 
difficult,  for  the  shortening  of  the  wrist,  the  palmar  prominence  of  the 
bones,  and  the  outward  shift  of  the  hand  are  not  found  in  them. 
From  isolated  dislocation  of  the  semilunar  it  may  well  be  difficult,  for 

Fig.  436. 


Midcarpal  fracture-dislocation  after  removal  of  semilunar  and  fragment 
of  scaphoid.     (Schoch.) 

there  is  the  same  palmar  prominence,  and  the  absence  of  shortening 
and  lateral  shift  may  be  made  uncertain  by  the  swelling.  Insensitive- 
ness  on  pressure  in  the  tabatiere  (fracture  of  scaphoid)  might  help. 
Sensitiveness  on  pressure  over  either  styloid  process  would  ])oint  to 
fracture-dislocation.  Medio-carpal  dislocation  is  rare  and  would  have 
to  be  recognized  by  tracing  the  upper  edge  of  the  projecting  row.  If 
the  a^-rays  are  used  lateral  and  antero-]X)sterior  views  should  be  taken. 

If  the  displacement  is  uncorrected  the  patient  remains  long  di.sibled, 
as  time  passes  the  pain  and  sensitiveness  may  diminish  and  disappear 
and  the  hand  regain  a  considerable  measure  of  usefulness,  but  the 
motions  of  the  wrist  will  l)e  much  restricted  and  the  strength  of  the 
grip  lessened.  In  the  one  case  in  which  reduction  was  cfFected  there 
was  some  loss  of  mobility  in  the  wrist.  When  a  chronic  arthritis  en- 
sues all  motion  at  the  wrist  may  l)e  lost. 

The  choice  of  treatment,  to  be  determined  l)v  the  extent  of  the  lesions 
and  the  possibilities,  lies  between  simple  reduction,  operative  reduction, 


7g2  mSLOCATlOM. 

aud  extirpation  of  one  or  more  of  the  bones.  If  reduction  fails  and 
operation  is  rejected,  the  wrist  must  be  immobilized  with  the  fingers  free, 
and  massage  and  moderate  passive  motion  used  after  a  week  or  two. 

For  simple  redaction  strong  traction  should  be  made  on  the  hand  to 
recreate  the  gap  between  radius  and  os  magnum,  perhaps  with  full 
dorsal  flexion  as  recommended  by  Codnian  in  dislocation  of  the  semi- 
lunar alone,  pressure  from  the  palmar  side  to  force  the  semilunar  back 
into  place,  and  then  palmar  flexion.  This  latter  position  should  be 
maintained  by  the  dressing,  and  Schoch  advises  that  an  a?-ray  plate 
should  be  made  after  the  application  of  the  dressing  to  detect  a  re- 
newal of  the  dislocation  if  it  should  have  taken  place.  The  histories 
show  that  in  most  of  the  cases  (including  probably  some  of  the  semi- 
lunar alone)  the  reduction  proved  not  to  have  been  complete  or  to  have 
recurred. 

Operative  reduction,  successful  in  one  case,  gave  a  result  that  was  not 
very  satisfactory  in  respect  of  function.  The  operation  of  choice  ap- 
pears to  be  the  early  removal  of  the  semilunar  and  the  proximal  fragment 
of  the  scaphoid,  by  an  incision  alongside  the  tendon  of  the  palraaris 
longus.  Delbet  recommends  the  removal  of  the  semilunar  even  in 
those  cases  in  which  it  has  preserved  its  relations  with  the  radius.  The 
results  thus  far  have  been  more  satisfactory  than  those  obtained  by 
other  methods.  It  is  also  supported  by  recent  experience  with  fractures 
of  the  scaphoid  (q.  v.). 

Isolated  Dislocation  of  the  Different  Bones  of  the  Carpus. 

This  is  a  very  rare  injury  except  in  the  case  of  the  semilunar,  yet 
instances  have  been  reported  of  the  dislocation  of  almost  every  one  of 
them.  Eigenbrodt^  has  made  a  large,  though  somewhat  uncritical, 
collection  of  reported  cases.     See  also  Sulzberger."^ 

Scaphoid.  The  reported  cases  of  dislocation  of  the  unbroken  scaphoid 
number  about  ten,  and  in  some  of  these  the  accuracy  of  the  diagnosis 
may  perhaps  be  questioned.  One  in  which  the  diagnosis  was  con- 
firmed by  arthrotomy  was  reported  by  King.^  In  most  the  dislocation 
was  backward,  and  in  two  reduction  was  made  by  direct  pressure. 
For  dislocation  of  a  portion  of  the  bone,  see  Fracture  of  the  Scaplioid 
and  Dislocation  of  the  Semilunar. 

A  supposed  case  of  backward  dislocation  was  observed  at  the  Hudson 
Street  Hospital  in  1899.  The  injury  was  an  old  one,  the  patient 
applying  for  some  other  affection.  The  lesion  was  carefully  examined 
by  two  members  of  the  house-staff,  who  concurred  in  the  diagnosis.  In 
Nov.,  1904, 1  saw  a  case  there  in  which  both  scaphoids  had  been  partly 
displaced  backward  at  the  central  end.  There  was  so  little  pain  and 
swelling  that  I  doubted  the  recent  traumatic  character  of  the  condition, 
but  the  patient  insisted  that  it  was  new  and  caused  by  forced  palmar 

1  Eigenbrodt:  Beitrage  zur  klin.  Chir.,  1901,  vol.  xxx.  p.  305. 

2  Sulzberger  :  Fortschritte  ans  dem  Geb.  der  Roentgenstrahlen,  1901-2,  vol.  v.  p,  5. 

3  For  cases  and  retercnces  see  Eigenbrodt. 
*  King:  Annals  of  Surgery,  August,  1899. 


DISLOCATIONS  OF  CARPAL  BONES.  783 

flexion.  The  displacement  was  irreducible  and  the  interference  with 
function  slight.    The  .r-rays  confirmed  the  diagnosis. 

Another  case  has  been  recently  reported  by  Senechal  ^ ;  the  injury 
had  existed  fifteen  years  and  flexion  and  extension  limited  one-half. 
The  proximal  end  of  the  bone  projected  on  the  dorsum  on  the  inner 
side  of  the  tendon  of  the  long  extensor  of  the  thumb.  The  pro- 
jecting portion  was  chiseled  away,  with  improvement  in  function. 
RiedP  reports  a  forward  dislocation  by  a  fall,  easily  reduced  by 
pressure. 

A  case  of  dislocation  forward  of  the  scaphoid  complicating  fracture 
of  the  lower  end  of  the  radius,  in  which  the  bone  was  removed  through 
an  incision,  was  reported  by  Cameron.*  Six  years  later  he'*  again 
reported  the  case,  this  time  as  one  of  dislocation  of  the  semilunar 
bone,  but  made  no  mention  or  explanation  of  the  previous  statement 
concerning  it,  although  he  described  the  case  in  the  same  terms  as 
before. 

Semilunar.^  In  the  last  few  years  the  .r-rays  have  shown  that  dislo- 
cation of  the  semilunar  bone,  either  alone  or  in  combination  with  frac- 
ture of  the  scaphoid  or  with  disturbance  of  the  relations  of  other  carpal 
bones,  is  far  from  uncommon  and  is  second  in  order  of  frequency  to 
fracture  of  the  scaphoid.  See  also  preceding  section  Miclcarpal  Frac- 
ture-dislocation. 

The  displacement  is  always  forward  with  rotation  on  the  transverse 
axis.  In  Erich  sen's  case  of  alleged  backward  dislocation  the  identity 
of  the  displaced  bone  was  not  positively  determined.  The  bone  lies 
beneath  the  flexor  tendons  opposite  its  site  or  a  little  higher  on  the 
radius,  and  in  the  extreme  cases  it  may  slip  past  the  tendons  and  make 
the  dislocation  compound  by  rupture  of  the  overlying  skin. 

It  is  habitually  produced  by  dorsal  flexion  of  the  wrist,  and  while 
the  mode  of  production  is  still  in  dispute  von  Lesser's  explanation 
appears  to  be  the  most  plausible.  He  describes  three  stages,  supported 
by  clinical  evidence  and  skiagrams  (Fig.  437).  In  the  first,  during 
dorsal  flexion,  the  palmar  apex  of  the  bone  is  fixed  by  the  strong 
palmar  ligaments  and  the  dorsal  apex  presses  against  the  head  of  the 
OS  magnum  (stage  of  subluxation).  Then  the  dorsal  apex  slides  along 
the  head  into  tlie  gap  between  the  scaphoid  and  os  magnum  and  reaches 

1  Sengchal:  Gaz.  des  Hop.,  1906,  p.  1515. 

2  Riedl :   Wiener  klin.  Wochenschrift,  1900,  p.  1520. 

3  Cameron :   Glasgow  Medical  Journal,  1878. 
*  Ibid :  Lancet,  1884,  vol.  i.  p.  885. 

5  The  references  are:  Mougeot,  quoted  by  Malgaigne;  Flower  and  Hulke,  Holmes's- 
System  of  Surgery,  Am.  ed,,  vol.  i.  p.  881;  Erichsen,  Science  and  Art  of  Surgery, 
Am.  ed.,  1873,  vol.  i.  p.  421;  Taafe,  British  Medical  Journal,  1869,  vol.  i.  p.  335,  Chis. 
olm,  Philadelphia  Medical  Times,  1870-71,  vol.  i.  p.  335;  Gross,  Philadelphia  Medical 
Times,  1880-81.  vol.  xii.  p.  220 ;  Buchan  an.  Medical  Times  and  Gazette,  1885,  vol.  i.  p. 
113 ;  Forgue,  Gaz.  hebdom.  de  Montpellier,  1887,  vol.  ix.  No.  1 ;  Albertin  La  Province 
Medic  ale,  1887,  p.  420,  and  a  second  case  in  Lyon  Medical,  December  9, 1894 ;  Gamgee, 
Lancet,  July  6,  1895;  Stimson,  New  York  Medical  Journal,  January  3,  1891,  p.  20;  a 
second  case  in  Annals  of  Surgery,  March,  1898,  p.  265;  Bolton,  Ibid.,  August,  1901,  p. 
291 ;  Richon,  Arch,  de  Med.  et  Pharm.  Mil.,  1903,  No.  3  ;  Steffel,  Arch,  fiir  klin.  Chir., 
vol.  Ixiii.  Part  I.;  v.  Lesser,  Deutsche  Zeitschrift  fiir  Chir.,  1902,  vol  Ixvii.  p.  488; 
Wittek,  Arch,  fiir  klin.  Chir.,  1904,  vol.  xlii.  p.  578;  Wendt,  Miineh  Med.  Wochen- 
schrift, 1904,  No.  24 ;  Codman  and  Chase,  Annals  of  Surg..  June,  1905;  Hildebrandt, 
Berl.  klin.  Wochenschrift,  1905,  p.  9.35;  Lilienfeld^  Arch,  fiir  klin.  Chir.,  vol.  Ixxvi.  p. 
641;  Montaudon,  Beitriige  zur  klin.  Chir.,  vol.  Ivii.  p.  9.    See  also  Eigenbrodt. 


DISLOCATIONS. 


the  palmar  side  of  the  carpus  (complete  dislocation),  its  lower  concave 
surface  directed  forward  ;  the  bone  may  lie  opposite  its  normal  position 
or  higher  up  on  the  radius.    In  the  third  stage  the  rotation  may  increase  to 

Fig.  437. 


1.  2.  3. 

Three  stages  of  dislocation  of  the  semilunar,    (v.  Lessen.) 

1 80°.  It  is  interesting  to  note  in  this  connection  that  in  two  of  Couteaud's 
cases  of  compound  dislocation  of  the  wrist  the  semilunar  remained  at- 
tached to  the  radius  and  was  once  accompanied  by  a  piece  of  the  cunei- 

FiG.  438. 


Dislocation  of  semilunar  bone. 


form.     The  palmar  ligament  uniting  the  radius  and  semilunar  usually 
remains  untorn  ;  that  uniting  the  semilunar  and  os  magnum  is  torn. 

Pressure  upon  the  tendons  may  keep  the  fiugers  partly  flexed,  and 
there  may  be  numbness  or  pain  in  the  distribution  of  the  niedian  nerve. 


DISLOCATIONS  OF  CARPAL  BONES  785 

The  diagnosis  is  made  bv  recoornition  of  tlie  bone  under  the  flexor  ten- 
dons and  of  the  gap  on  the  dorsum  between  the  os  magnum  and  radius. 

In  some  uncomplicated  cases  reduction  has  apparently  been  efl'ected 
by  manipulation,  but  in  a  number  of  them  (Codman,  Hildebrandt) 
later  examination  showed  that  reduction  had  been  incomplete  or  that 
the  displacement  had  recurred.  It  is,  I  think,  evident  that  the  sur- 
geon cannot  be  certain  that  he  has  fully  reduced  or  that  the  bone  will 
remain  in  place,  and  as  removal  of  the  bone  has  given  as  good  func- 
tional results  as  reduction  has,  the  surgeon  is  justified,  I  think,  in 
resorting  to  removal  at  once.  Nevertheless,  late  removal  seems  to 
give  equally  good  results.  In  compound  cases  immediate  removal  is 
indicated.  Ohly  ^  successfully  reduced  by  operation  forty-five  days 
after  injury. 

For  reduction  Codman  recommends  that  the  wrist  should  be  hyper- 
extended,  the  bone  pushed  into  place  and  held  there  with  the  thumbs 
while  the  wrist  is  flexed. 

Unciform.  There  are  four  recorded  cases.  One  is  very  briefly  re- 
ported by  Buchanan  ^ :  a  man  fell  from  a  railway  car ;  "  he  was  found 
to  have  a  simple  luxation  of  the  unciform  bone  anteriorly.  It  lay  just 
beneath  the  skin,  and  its  process  could  be  distinctly  outlined.  Reduc- 
tion was  effected  by  direct  pressure  on  the  bone  while  the  borders  of 
the  hand  were  approximated."  Another  is  reported  by  Eigenbrodt.  He 
excised  the  bone  ;  the  process  had  been  broken  off.  In  the  third  ^  the 
hand  had  been  crushed  in  a  machine,  with  a  ragged  wound  on  the 
thenar  eminence.  The  a;-ray  showed  the  unciform  freed  from  all  its 
attachments  and  displaced  forward.  No  attempt  to  reduce.  Seven 
months  later  flexion  of  the  wrist  was  restricted,  the  fingers  could  not 
be  fully  closed,  but  the  man  was  at  work.  The  fourth  is  reported  by 
Van  Assen  {Ztlblatt  fur  Cliir.,  1910,  p.  1129),  an  anterior  dislocation 
with  fracture  of  the  scaphoid.  The  unciform  was  removed;  some  limi- 
tation of  motion. 

Pisiform.  The  pisiform  has  been  reported  dislocated  in  five  cases  :  in 
two  (Erichsen,  Fergusson)  by  muscular  effort;  in  one  (Gras*)  by  the 
pressure  of  the  hand  upon  a  flat-iron  while  ironing  clothes.  In  Erich- 
sen's  case  tile  bone  was  drawn  up  the  arm  for  a  distance  of  nearly  an 
inch.  Doubtless  the  displacement  was  the  result  of  rupture  of  the 
tendon  below  the  bone. 

Os  Magnum.  Many  authors  speak  of  partial  dislocation  of  the  head 
of  the  OS  magnum  backward  as  a  not  infrequent  accident  jiroduced  by 
prolonged,  perhajis  not  violent,  use  of  the  hand,  or  by  a  sudden  effort, 
or  a  fall.  Malgaigne  classifies  the  former  as  pathological  dislocations ; 
they  are  characterized  by  the  appearance  on  the  back  of  the  wrist  just 
above  the  base  of  the  third  metacarpal  bone  of  a  small,  hard,  round 
lump,  especially  during  palmar  flexion,  Mdiich  disappears  more  or  less 
completely  during  dorsal  flexion,  and  can  sometimes  be  temporarily 
reduced  by  pressure.     It  ordinarily  causes  little  or  no  disability. 

1  Ohly  :  Deutsche  Zeitschrift  fiir  Chir..  vol.  xciii.  p.  218. 

2  Buchanan  :   Philadelphia  Medical  and  Surgical  Rejiorter.  1881-82,  vol.  xlvi.  p.  418. 

3  Ebermayer :  Fcirtsehritte  aus  dem  Geb.  dcr  Koentgenstrahlen,  1908,  vol.  xii.  p.  1. 
*  Gras  :  Gazette  Medicale,  1835,  p.  542. 


786  DISLOCATIONS. 

Tlie  more  distinctly  traumatic  cases  are  those  of  Richerand  (quoted 
by  Cooper^)  and  Seeger  (quoted  by  Tillmanns).  Richerand's  patient 
was  a  woman  who  grasped  the  side  of  lier  bed  (hiring  parturition,  turn- 
ing her  wrist  forward,  and  felt  a  sharp  pain  in  the  wrist.  A  fortnight 
later,  a  hard,  circumscribed  tumor  was  found  at  the  back  of  the  carpus, 
formed  by  the  head  of  the  os  magnum,  which  was  readily  replaced  by 
making  gentle  pressure  on  it,  and  extending  the  hand.  Richerand 
had  seen  another  similar  case,  as  had  also  Chopart  and  Boyer. 

Cooper's  patient  was  a  young,  muscular  man,  who  had  fallen  upon 
his  hand  in  such  a  way  as  to  bring  the  palmar  aspect  of  the  fingers 
into  contact  with  the  forearm.  At  the  point  of  most  pain  was  a  round, 
hard  tumor,  rather  larger  than  a  marble,  which  produced  a  most  evi- 
dent deformity  on  the  back  of  the  wrist  opposite  to  and  above  the  base 
of  the  third  metacarpal.  The  hand  was  slightly  bent,  and  extension 
caused  considerable  pain  ;  the  tendon  of  the  extensor  carpi  radialis 
brevior  was  displaced  slightly  to  the  radial  side ;  the  forefinger  was 
abducted  from  the  middle  one,  and  any  attempt  to  approximate  them 
gave  great  pain  at  the  base  of  their  metacarpal  bones ;  and  opposite 
the  base  of  the  middle  one  was  a  depression,  quite  evident  to  both  sight 
and  touch.  Reduction  was  effected  by  making  traction  on  the  fore  and 
middle  fingers,  while  pressure  was  made  upon  the  os  magnum.  On 
flexing  the  hand  the  deformity  was  reproduced  ;  it  was  again  corrected, 
and  the  hand  placed  in  splints. 

Seeger^  saw  in  1829  and  1830  two  cases  of  dislocation  of  the  head 
of  the  OS  magnum  backward  caused  in  young  men  by  falls  upon  the 
closed  fist.  Reduction  was  effected  by  traction  and  forcible  flexion  of 
the  hand,  in  one  case  easily,  in  the  other  only  after  several  attempts. 
The  hand  was  kept  in  splints  in  the  extended  position  from  six  to  eight 
weeks,  with  compresses  in  front  and  behind.     Recovery  was  complete. 

The  only  case  of  total  dislocation  of  the  bone  of  which  I  know  was 
in  a  patient  who  applied  at  the  Hudson  Street  Hospital  in  1899 
because  of  another  injury.  A  lump  was  noticed  at  the  back  of  his 
wrist,  which  he  said  dated  from  an  injury  received  nine  years  before. 
Two  skiagrams,  taken  at  the  time  (Plate  XXXYII),  clearly  show 
the  three  bones  of  the  first  row  in  place  and  the  projection  of  the 
dislocated  bone  over  the  site  of  the  os  magnum.  There  was  no  loss  of 
function. 

Trapezoid.  The  diagnosis  of  dislocation  of  the  trapezoid  backward 
was  made  in  a  case  reported  by  Gay  ;^  the  patient  was  a  man,  thirty- 
two  years  old,  and  the  injury  was  caused  by  striking  with  the  fist  in 
play.  "  At  the  base  of  the  metacarpal  bone  of  the  index-finger  was  a 
sharp,  hard,  slightly  movable  bunch,  raised  one-quarter  of  an  inch,  and 
tender  on  pressure."  There  was  no  crepitus ;  the  metacarpal  bones 
were  of  the  same  length.  It  could  not  be  reduced.  Two  months  later 
the  deformity  was  unchanged,  but  the  hand  had  become  nearly  as  good 
as  the  other.     Sheldon  *  reports  an  almost  identical  case. 

^  Cooper :  Loc.  cit.  p.  434. 

2  Seeger:  Mittheilungen  der  Wiirtt.  arztl.  Vereiiis,  vol.  i.,  quoted  by  Tillmaiiiis. 

3  Gay:  Bo.ston  Medical  and  Surgical  Journal,  1869,  vol.  Ixxxi.  p.  188. 
*  Sheldon:  American  Journal  Medical  Science,  January,  1901. 


PLATE  XXXVII 


Fig.  1. — Old  Dislocation  Backward  of  the  Os  Magnum. 


Fig.  2. — Same   as    Fig.  1. 


CABPO-METACAEPAL  DISLOCATIONS.  787 

Trapezium.  Two  cases  of  dislocation  backward  of  the  trapezium  alone 
have  been  reported  by  Uhde^  and  von  Mosengeil.^ 

Uhde's  patient  was  a  man,  thirty-three  years  old,  who  had  been 
knocked  down  by  a  wagon.  The  right  thumb  and  the  region  of  its 
metacarpal  bone  was  bruised,  swollen,  and  painful,  and  "at  the 
junction  of  the  first  metacarpal  and  trapezium  an  unusual  mobility 
of  the  latter  bone  was  recognizable,  and  instead  of  the  normal  depres- 
sion between  the  tendons  of  the  extensor  secundi  and  extensor  prirai 
internodii  on  extension  of  the  hand  there  was  to  be  seen  a  small 
angular  tumor  corresponding  to  the  trapezium,  which  projected  on 
flexion  of  the  first  and  second  metacarpals  about  three  and  a  half  lines 
above  the  level  of  the  back  of  the  hand,  and  disappeared  on  straight 
extension  of  these  bones  with  a  creaking  sound.  Six  months  later  the 
trapezium  was  found  to  project  one  and  a  half  lines  on  the  radial  side." 

Von  Mosengeil's  patient  had  a  deformed  hand,  the  thumb  and  its 
metacarpal  bone  having  the  shape  and  position  of  a  finger  ;  the  dis- 
placement, half  a  centimetre,  was  produced  by  a  blow  received  upon 
the  palm  of  the  hand  ;  it  was  reduced  by  flexion  and  pressure. 

There  is  one  case  in  the  records  of  the  out-patient  department  of  the 
Hudson  Street  Hospital.  It  did  not  come  under  my  observation,  and 
the  details  are  lacking  in  the  report. 

Os  Magnum  Trapezoid.  Uhde'  briefly  describes,  under  the  title 
"luxatio  ossis  multanguli  minoris  et  ossis  capitati,"  a  case  of  injury  to 
the  wTist  marked  by  a  projection  on  the  back  of  the  hand,  which  he 
attributed  to  the  displacement  of  the  trapezoid  and  os  magnum.  The 
injury  was  caused  by  a  fall  upon  the  "anterior  ends  of  the  metacarpal 
bones."  It  does  not  appear  from  the  description  whether  the  bones 
were  thought  to  be  dislocated  from  the  metacarpals  as  well  as  from  the 
first  row  of  the  carpus.  The  prominence  could  be  reduced  by  pressure, 
and  reappeared  on  flexion  of  the  wrist. 

A  case  reported  by  Alquie,  of  Montpellier,  has  been  frequently 
quoted  ;  there  was  much  displacement  of  the  carpal  bones  on  the  radial 
side,  but  not  only  was  its  character  uncertain,  but  in  addition  the  region 
had  suffered  from  two  different  accidents,  one  of  which  was  accompa- 
nied by  great  laceration  of  the  soft  parts. 

CARPOMETACARPAL  DISLOCATIONS. 

Cases  have  been  reported  of  the  isolated  dislocation  of  every  one  of 
the  metacarpal  bones  except  the  fifth,  and  of  the  combined  dislocation 
of  two  or  more. 

First  Metacarpal.  Dislocations  of  the  metacarpal  bone  of  the  thumb 
are  the  most  frequent  and  important;  almost  all  have  been  back- 
ward. 

Very  little  is  known  of  flislocations  forimnJ.  Sir  Astley  Cooper* 
says,  "  In  the  cases  wliich  I  have  seen  of  this  accident  the  metacarpal 
bone  has  been  thrown  inward,  between  the  trapezium  and  the  root  of 
the  metacarpal  bone  supporting  the  index-finger  ;  it  forms  a  protuber- 

'  Uhde  :  Deutsche  Klinik,  ISoO,  vol.  ii.  p.  530. 

■-  Von  Mosengeil:  Arch,  fur  klin.  CbinirKic.  Ibil.  vol.  xii.  p.  723. 

'  Uhd^! :  Loc.  cit.  *  Cooper  :  Lou.  cit.,  p.  443. 


788  DISLOCATIONS. 

ance  toward  the  palm  of  the  hand ;  the  thumb  is  bent  backward  and 
cannot  be  brought  toward  the  little  finger."  Poinsot  quotes  a  reference 
by  Vidal  de  Cassis  to  a  case  of  incomplete  dislocation  forward  which 
he  had  easily  reduced. 

Albert^  saw  two  cases  of  incomplete  dislocation  outward;  one  was 
old,  the  other  recent.  In  the  latter  the  injury  was  produced  in  a  trial 
of  strength  by  grasping  hands.  The  displacement  was  easily  reduced, 
but  immediately  recurred.  After  reduction  the  thumb  was  fixed  in 
abduction  by  a  silicate  dressing  and  so  maintained  for  six  weeks. 
Complete  recovery. 

Dislocations  backward  may  be  complete  or  incomplete ;  the  former 
are  infrequent,  the  latter  quite  common.  Of  the  73  cases  of  metacarpal 
dislocation  in  my  statistics  (Chapter  XXVII.)  almost  all  were  of  this 
bone  and  of  this  kind.  The  cause  may  be  a  forced  flexion  of  the 
thumb  into  the  palm  of  the  hand,  or  its  forced  movement  in  the  oppo- 
site direction,  or  direct  violence  received  upon  the  thenar  eminence, 
as  in  striking  upon  the  handle  of  a  chisel,  or  in  striking  a  blow  with 
a  hammer,  or  in  the  bursting  of  a  gun. 

Specimens  of  old  dislocation  have  been  dissected  by  Foucher^  and 
G6rin-Roze ;  ^  in  the  former  the  upper  end  of  the  metecarpal  bone  was 
displaced  backward  and  a  little  inward,  and  was  flexed  at  a  right  angle 
to  and  fused  with  the  trapezium  ;  in  addition,  the  second  metacarpal 
was  displaced  upward  about  two  centimetres  on  the  back  of  the  wrist, 
retaining  the  insertion  of  the  extensor  carpi  radialis,  and  the  third 
metacarpal  had  been  broken  at  its  middle.  The  injury  was  caused  by 
the  bursting  of  a  gun.  In  Gerin-Roze's  case  the  displacement  was 
directly  backward,  the  anterior  edge  of  the  base  of  the  metacarpal  rest- 
ing upon  the  posterior  edge  of  the  inferior  articular  surface  of  the 
trapezium  ;  incomplete  reduction  could  be  made. 

In  the  incomplete  form  the  posterior  edge  of  the  base  of  the  meta- 
carpal bone  can  be  seen  and  felt  in  the  interval  between  the  tendons  of 
the  extensor  primi  and  extensor  secundi  internodii  as  a  hard  lump 
continuous  with  the  shaft  of  the  bone  and  reducible  by  pressure.  The 
thumb  is  generally  somewhat  flexed  toward  the  palm,  but  may  be 
extended  or  "  straight."  Movement  is  limited  and  ])ainfu],  and  flex- 
ion increases  the  apparent  displacement. 

In  the  complete  form  the  dorsal  prominence  is  more  distinct,  and 
rests  upon  the  trapezium  which  forms  a  recognizable  lump  in  the  ball 
of  the  thumb.  The  thumb  is  shortened  by  the  ascent  of  the  meta- 
carpal bone,  its  first  phalanx  appearing  in  consequence  to  have  passed 
upward  into  the  thenar  muscles,  and  it  is  usually  flexed  at  the  carpo- 
metacarpal joint. 

In  some,  even  recent,  cases  reduction  has  been  impossible,  but  usually 
it  has  been  eifected  without  difficulty  by  traction  on  the  thumb  and 
direct  pressure  forward  and  downward  upon  the  projecting  end  of  the 
bone.  Early  recurrence  has  been  noted  in  some  cases,  and  in  a  few 
prevention  of  recurrence  has  been  diflieult  or  incomplete.     Moulded 

1  Albert:  Chirurgie,  vol.  ii.  p.  445. 

^  Foucher :  Bull,  dc  la  Soc.  Anatomique.  18.56,  p.  6. 

'  Gerin-Roze :  Bull,  de  la  Soc.  Anatomique,  1858,  p.  266, 


CARPO-METAGARPAL   DISLOCATIONS.  789 

splints  of  leather,  plaster,  or  gutta-percha,  and  pasteboard  or  wooden 
splints  with  compresses  at  the  back  of  the  joint  are  ordinarily  used,  and 
have  given  satisfactory  results.  In  one  case  the  only  dressing  con- 
sisted of  strips  of  adhesive  plaster,  running  from  the  back  of  the  forearm 
around  the  ball  of  the  thumb,  and  back  between  it  and  the  index-finger 
to  the  forearm,  so  as  to  maintain  the  member  abducted  and  extended. 

The  restoration  of  function  after  reduction  is  complete,  and  even 
when  the  dislocation  has  remained  unreduced  some  patients  have  been 
able  to  make  good  use  of  the  thumb ;  in  others  the  movement  of 
adduction  and  opposition  has  been  much  restricted. 

The  second  metacarpal  has  been  reported  dislocated  forward  in  two 
cases  and  backward  in  six  cases ;  in  one  of  the  latter  together  with 
dislocation  of  the  first,  and  in  another  with  dislocation  of  the  third. 
An  additional  case,  observed  by  himself,  is  mentioned  by  Demarquay,'^ 
in  which  the  first  and  second  were  together  dislocated,  but  the  direction 
is  not  stated,  and  no  details  are  given. 

The  forward  cases  are  those  of  Bourget  (quoted  by  Malgaigne)  and 
Marsh  (quoted  by  Hamilton).  In  Bourget's,  the  cause  was  excessive 
pressure  on  the  upper  posterior  part  of  the  bone  ;  in  Marsh's,  it  was 
an  oblique  blow  with  a  hammer  on  the  back  of  the  clenched  hand.  In 
both  cases  the  proximal  end  of  the  bone  could  be  felt  in  the  palm,  and 
a  corresponding  depression  on  the  back ;  in  the  former  case  the  lower 
end  of  the  bone  was  inclined  forward,  and  the  finger  appeared  short- 
ened nearly  one-fourth  of  an  inch.  Both  were  easily  reduced  by  trac- 
tion on  the  finger  and  pressure  on  the  end  of  the  bone. 

The  uncomplicated  backward  cases  are  those  of  Hamilton,^  Hum- 
bert,^ and  Lyman*;  the  former  was  caused  in  a  woman,  twenty-eight 
years  old,  by  a  fall  upon  the  closed  hand.  Reduction  was  easily 
effected.  Humbert's  patient  was  a  man  thirty  years  old,  who  was 
kicked  by  a  horse  upon  the  hand  that  held  the  reins,  the  blow  falling 
on  the  back  of  the  lower  end  of  the  second  metacarpal  bone  and  the 
adjoining  phalanx  ;  the  upper  end  of  the  bone  could  be  felt  as  a  hard, 
circumscribed  prominence  on  the  back  of  the  hand,  and  the  finger, 
measured  by  the  adjoining  one,  appeared  five  millimetres  short.  Re- 
duction was  made  by  traction  and  direct  pressure  downward  and  for- 
ward.    Lyman  had  to  incise  and  pry  the  bone  into  place. 

The  case  in  which  the  dislocation  was  associated  with  that  of  the 
first  metacarpal  is  that  of  Foucher,  mentioned  above. 

In  two  cases  seen  by  Hamilton  there  was  incomplete  dislocation  back- 
ward of  the  upper  end  of  the  second  and  third  metacarpals,  caused  by 
striking  a  blow  with  the  fist ;  in  both  cases  the  dislocation  was  old,  and 
iiad  persisted  in  spite  of  attempts  to  maintain  reduction. 

Third  Metacarpal.  In  addition  to  these  two  cases,  in  which  the  injury 
was  associated  with  dislocation  of  the  second  metacar])al,  dislocation 
backward  of  the  third  metacarpal  has  been  reported  by  Blandin^  and 
Roux.®      Blandin's    patient   fell,  Avhile   holding  a  roll  of  paper,  and 

1  Deiiiarquay  :   Bull,  de  la  Societc  dc  Clururgie,  18.")!.  vol.  ii.  p.  171. 

2  liuiuilton  :  Loc.  cit.,  p.  724.  ^  Humbert:  Union  Medicale,  IbOS,  vol.  v.  p.  o27. 
*  Lyman  :   Annals  of  Surj;.,  .June,  1906. 

^  Blandin  :  Gazette  des  Hopitaux,  1H44,  p.  oSS. 
>5  fioux:   Union  Medicale,  1«48,  p.  •224. 


790  DISLOCATIONS. 

struck  his  hand  against  a  post ;  the  blow  was  slight,  and  caused  no 
pain  at  the  time,  but  the  middle  finger  promptly  became  powerless, 
and  the  hand  numb  and  swollen.  There  was  a  linear  transverse  ecchy- 
mosis  at  the  back  of  the  first  phalanx  of  the  middle  finger,  close  by 
the  metacarpal  joint,  and,  on  movement,  a  crackling  that  resembled 
crepitus.  No  other  symptoms  are  mentioned.  Blandin  made  the  diag- 
nosis of  "  diastasis  or  incomplete  dislocation  "  of  the  third  metacarpal 
bone,  but  others  who  saw  the  case  thought  the  bone  was  broken.  The 
title  of  the  report  of  the  case  is  "  incomplete  dislocation  upward." 

Roux's  patient  had  been  injured  in  a  mine  explosion ;  a  hard,  cir- 
cumscribed, subcutaneous  tumor  could  be  seen  and  felt  on  the  back  of 
the  wrist,  continuous  and  moving  with  the  third  metacarpal ;  the  middle 
finger  was  shortened.  The  dislocation  was  reduced  by  direct  pressure, 
but  appears  to  have  recurred,  for  at  the  autopsy  the  base  of  the  bone 
was  found  resting  on  the  back  of  the  os  magnum  ;  the  second  meta- 
carpal was  broken. 

Fourth  Metacarpal.  An  incomplete  backward  dislocation  of  the 
fourth  metacarpal  was  reported  by  Maurice.^  It  was  caused  by  the 
premature  explosion  of  a  cartridge  which  the  patient  was  putting 
into  a  Chassepot  gun  ;  the  plunger  was  driven  backward  against  the 
palm  of  the  hand.  There  was  a  prominence  half  a  centimetre  high 
on  the  back  of  the  hand,  corresponding  to  the  upper  end  of  the  fourth 
metacarpal.     Reduction  was  easy,  and  recovery  prompt. 

The  four  inner  metacarpal  bones  (II.,  III.,  IV.,  V.)  have  been  simul- 
taneously displaced  in  four  cases,  Vigouroux,^  Hamilton,^  Tillaux,*  and 
one  of  my  own  ;  in  the  first  and  second  the  dislocation  was  backward, 
in  the  others  forward. 

Vigouroux's  patient  was  injured,  when  eighteen  years  old,  by  the 
explosion  of  a  pistol  which  he  held  in  his  left  hand.  At  his  death,  at 
the  age  of  sixty-two  years,  there  was  found  a  complete  dislocation 
backward  of  the  last  four  metacarpal  bones ;  these  bones  were  flexed 
forward  and  the  proximal  phalanx  of  each  of  the  last  three  fingers  was 
incompletely  dislocated  backward.  The  index-finger  and  the  lower 
part  of  its  metacarpal  bone  were  lacking.  All  the  joints  of  the  carpus, 
including  that  of  the  trapezium  and  first  metacarpal,  were  normal. 

Hamilton's  patient  was  struck  by  a  bullet  which  entered  at  the  ulnar 
side  of  the  hand  and  crossed  the  back  of  the  wrist  between  the  last  row 
of  carpal  bones  and  the  skin.  When  seen  by  Hamilton  five  years  later 
"the  displacement  (backward)  was  very  conspicuous  ;  no  fragments  of 
bone  had  ever  escaped.  The  movements  of  all  the  fingers,  except  the 
index-  and  little  fingers,  were  unimpaired." 

Tillaux's  patient,  whom  I  saw  when  he  was  admitted  to  the  Laribois- 
iere  Hospital,  was  twenty  years  old ;  twelve  days  before  admission  he  had 
fallen  backward  from  a  window,  about  ten  feet,  striking  upon  the  back 
of  his  flexed  hand.  The  hand  was  flexed  on  the  wrist  and  could  not 
be  actively  extended.  There  was  a  dorsal  depression  corresponding 
to  the  line  of  junction  of  the  carpal  and  metacarpal  bones,  sharply 

1  Maurice:  Gazette  Medicalc,  1868,  p.  587. 

2  Vigouroux  :  Bull,  de  la  Societe  Anatomique,  1856,  p.  15. 

3  Hamilton  :  Loc.  cit.,  p.  724. 

*  Tillaux:  Bull,  de  la  Societe  de  Chirurgie,  1875,  p.  415. 


CARPO-METACARPAL  DISLOCATIONS.  791 

limited  above  by  a  transverse  prominence  which  was  evidently  formed 
by  the  second  row  of  the  carpus,  and  on  the  palmar  surface  at  the 
same  level  the  ball  of  the  hand  was  more  prominent  than  usual.  The 
relations  of  the  first  metacarpal  with  the  trapezium  were  unchanged. 
Moderate  traction  with  direct  pressure  forward  reduced  the  displace- 
ment with  a  click,  and  by  making  pressure  in  the  opposite  direction  it 
was  again  produced.  After  a  second  reduction  the  limb  was  immobil- 
ized for  a  fortnight.     Complete  recovery. 

My  patient  was  a  lad  fifteen  years  old  who  was  admitted  to  the  Pres- 
byterian Hospital  in  January,  1887,  after  having  fallen  down  an  eleva- 
tor shaft,  a  distance  of  about  forty  feet,  and  received,  with  other  injuries, 
a  dislocation  of  the  left  carpo-metacarpal  joints.  When  I  first  saw  the 
patient,  three  weeks  later,  the  last-named  injury  had  not  been  recog- 
nized. The  hand  was  then  in  almost  complete  extension  on  the  wrist 
and  occupying  a  plane  somewhat  anterior  to  that  of  the  wrist  and  fore- 
arm. The  back  of  the  wrist  formed  a  rounded  resistant  prominence, 
continuous  above  with  the  back  of  the  radius  and  ulna  and  terminating 
below  in  a  sharp,  well-defined,  transverse  ridge,  which  extended  com- 
pletely across  from  the  fifth  to  the  second  metacarpal  and  curved  up- 
ward on  the  outer  side  toward  the  styloid  process  of  the  radius.  The 
finger,  passed  upward  along  the  back  of  the  metacarpus,  was  arrested 
by  this  ridge,  which  appeared  to  be  about  one-quarter  of  an  inch  high 
and  corresponded  to  the  line  of  the  carpo-metacarpal  joints.  The  first 
row  of  carpal  bones  was  in  normal  relations  with  the  forearm  and  with 
most  of  the  second  row,  but  the  relations  of  the  trapezium  could  not  be 
clearly  made  out.  I  was  under  the  impression  that  it  was  displaced 
somewhat  forward  from  the  scaphoid ;  it  had  preserved  its  relations 
with  the  first  metacarpal  bone.  The  ball  of  the  hand  was  abnormally 
prominent,  and  the  antero-posterior  diameter  of  the  wrist  appeared 
thereby  increased ;  the  transverse  diameter  was  unchanged. 

The  deformity  was  easily  reduced  by  traction  and  direct  pressure, 
but  immediately  recurred  when  the  pressure  was  removed.  Reduction 
was  maintained  for  ten  days  by  keeping  the  limb  in  a  ])laster-of-Paris 
dressing;  on  removal  of  the  dressing  the  deformity  did  not  recur,  but 
a  few  hours  later  the  patient  reproduced  it  while  experimenting  to 
ascertain  if  the  reduction  was  permanent.  It  was  again  reduced,  and 
the  limb  dressed  as  before.  Three  weeks  later  the  reduction  was  com- 
plete and  permanent  except  for  some  projection  forward  of  the  first 
metacarpal  and  trapezium,  and  the  wrist  and  the  fingers  had  regained 
their  mobility. 

Dislocation  of  All  Five  Metacarpals.  Poulet '  reported  a  case  of  incom- 
plete dislocation  forward  of  all  five  metacarpal  bones;  the  injury  was 
caused  by  a  fall  from  a  horse  and  was  associated  witli  a  wound  of  the 
skin  on  the  ball  of  the  hand  and  slight  chi]i])iug  of  the  anterior  edges 
of  the  carpal  bones.  The  swelling  and  the  inflammatory  reaction  were 
so  great  that  an  examination  Avas  not  made  until  after  the  lapse  of  a 
month.  There  was  then  found  on  the  back  of  the  hand  a  projection 
formed  mainly  l)y  the  os  magninn,  and  below  it  a  depression  extending 
from  the  trapezium  to  tiic  unciform.     On  the  nalniar  surface  the  ball 

1  Poulct ;  Bull,  de  la  Soc.  de  Chir.,  1884,  p.  902. 
55 


792  DISLOCATIONS. 

of  the  hand  projected  forward,  the  palmar  fold  was  effaced,  and  a  deep, 
ill-defined  bony  prominence  could  be  felt.  The  interdigital  spaces  were 
two  centimetres  nearer  the  styloid  processes  than  on  the  other  hand. 
Partial  reduction  and  restoration  of  mobility  were  obtained. 

Erichsen  gives  a  woodcut  and  description  of  a  plaster  cast  in  the 
University  College  Museum,  London,  taken  from  a  patient  in  whom 
he  thinks  this  dislocation  must  have  existed ;  and  Rivington  ^  reported 
the  case  of  a  patient  who  had  been  run  over  by  a  wagon  and  had  sus- 
tained a  compound  dislocation  forward  of  all  the  metacarpal  bones, 
the  base  of  the  third  projecting  through  a  transverse  wound  near  the 
centre  of  the  palm  ;  the  first  phalanx  of  the  thumb  was  also  dislocated, 
and  the  index-finger  so  injured  that  its  amputation  was  necessary. 
The  base  of  the  third  metacarpal  was  excised  and  the  dislocation 
centre  of  the  palm  ;  this  w^as  excised  and  the  dislocation  reduced.  After 
dangerous  suppuration  and  high  fever  the  patient  recovered  with  a 
fairly  useful  hand. 

1  Kivington  :  Lancet,  1873,  vol.  i.  p.  270. 


CHAPTER    XLIX. 

DISLOCATIONS  OF  THE  THUMB  AND  FINGEKS. 

Proximal   Phalanx    of    Thumb — of    the    Fingers — Middle    Phalanges — Distal 

Phalanges. 

The  tables  in  Chapter  XXVII,  show  that  metacarpo- phalangeal 
dislocations  of  the  thumb  and  fingers  and  dislocations  of  the  phalanges 
in  combined  hospital  and  polyclinic  services  amount  to  nearly  25  per 
cent,  of  all  dislocations.  Of  the  metacarpo-phalangeal  dislocations 
those  of  the  thumb  are  much  the  most  numerous. 

DISLOCATIONS  OF  THE    PROXIMAL  PHALANX  OF  THE  THUMB. 

These  dislocations  are  not  only  the  most  frequent  of  those  involving 
the  phalanges,  but  they  also  derive  a  special  interest  from  the  fre- 
quency with  which  the  reduction  has  been  found  to  be  very  difficult 
or  has  entirely  failed.  The  cause  of  this  difficulty  has  been  the  sub- 
ject of  much  study  and  experiment  upon  the  cadaver  during  the  last 
hundred  years,  which  may  be  said  to  have  culminated  in  an  elabo- 
rate paper  read  by  Farabeuf  ^  before  the  Societe  de  Chirurgie  of  Paris 
in  1875,  in  which  the  anatomy  of  the  joint  was  described  with  much 
detail.  This  description  and  his  explanation  of  the  cause  of  the  diffi- 
culty have  been  generally  copied  and  accepted  by  writers  in  Germany 
and  France.  The  experience  I  have  gained  in  arthrotomies  indicates 
that  he  somewhat  overestimated  the  importance  of  the  sesamoid  bones 
in  opposing  reduction. 

Anatomy.  The  head  of  the  metacarpal  bone  projects  on  its  palmar 
aspect  in  the  form  of  a  well-rounded  tubercle  or  condyle  covered  with 
cartilage,  and  more  prominent  on  its  outer  than  on  its  inner  side. 
The  ligaments  of  the  joint  here  concerned  are  the  two  lateral  and  the 
strong  anterior  or  glenoid  ;  the  latter  is  continuous  on  either  side  with 
the  others  and  is  stiffened  by  the  development  within  it  of  the  two  sesa- 
moid bones  belonging  to  the  short  muscles  attached  to  the  base  of  the 
phalanx.  The  tendon  of  the  flexor  longus  pollicis  lies  nearer  the  inner 
than  the  outer  side  ;  it  is  lodged  at  its  lower  end  in  a  firm  sheath,  which 
extends  upward  to,  and  is  connected  with,  the  glenoid  ligament. 

The  short  muscles  and  their  attachments  are  made  tense  by  alxluct- 
ing  the  thumb,  and  are  relaxed  by  jiressing  the  metacarpal  bone  into 
the  palm  of  the  hand.  The  long  flexor  and  the  extensors  are  relaxed 
by  inclination  of  the  hand  toward  the  radial  side.  Consequently,  to 
relax  as  much  as  possible  the  various  muscles  attached  to  the  thumb, 
the  hand  should  be  held  in  straight  extension  and  slight  abduction, 
and  the  thumb  should  be  pressed  into  the  ])alm,  nddiiction. 

1  Farabouf :  Bull,  de  la  Societe  de  Chirurgie,  IbTU,  p.  L'l. 

(  7'.):3 ) 


794 


DISLOCATIONS. 


The  dislocation  may  be  backward,  forward,  or  to  the   inner  side ; 
complete  or  incomplete. 


Backward  Dislocations. 

This  is  the  most  frequent  form,  and  the  one  in  which  reduction  of 
the  dislocation  is  often  difficult. 

The  common  cause  is  exaggerated  dorsal  flexion  of  the  first  phalanx. 
When  the  normal  limit  of  the  movement  is  reached  the  anterior  liga- 
ment is  put  upon  the  stretch  and,  the  movement  being  continued,  yields 
at  its  attachment  to  the  metacarpal  bone,  so  that  the  anterior  ligament 
accompanies  the  phalanx  in  its  movement. 


Fig.  439. 


Fig.  440. 


Incomplete  dislocation  of  tlie  thumb. 


Incomplete  dislocation.    (Fakabexjf.) 


a.  Incomplete  Form.  If  this  movement  is  not  carried  further  than 
to  the  position  shown  in  Fig.  439  the  articular  end  of  the  phalanx  rests 
against  the  posterior  margin  of  the  head  of  the  metacarpal  bone,  and 
is  maintained  in  this  position  by  the  tension  of  the  portions  of  tlie 
adductor  and  abductor  muscles  which  are  attached  directly  to  the 
phalanx,  for  their  line  of  traction  is  now  posterior  to  and  above  the 
new  centre  of  motion.  The  attitude  of  the  member  is  represented  in 
Fig.  440. 

This  incomplete  form  is  the  one  which  many  people,  especially  the 
young,  can  voluntarily  produce  by  contracting  the  extensor  muscles. 
The  anterior  ligament  and  the  sesamoid  bones  rest  like  an  apron 
against  the  antero-inferior  articular  surface  of  the  metacarpal  bone, 
and  the  dislocation  can  be  readily  reduced  by  moderate  traction  upon 
the  phalanx  and  flexion. 

6.  Complete  Form.  If,  however,  the  movement  is  carried  further, 
the  phalanx  entirely  leaves  the  articular  surface  of  the  metacarpal 
bone,  and  moves  upward  on  its  dorsum,  being  followed  by  the  anterior 
ligament  and  the  sesamoid  bones  (Figs.  441  and  442).  The  external  lat- 
eral ligament  is  torn,  and  usually  the  internal  one  also  ;  the  tendon  of  the 
flexor  longus  poUicis  may  remain  in  position,  and  be  tightly  stretched 
across  the  articular  face  of  the  metacarpal  bone,  as  has  been  seen  in 
some  compound  dislocations  (e.  g.,  Esmarch  ^),  or,  and  much  more  com- 
monly, it  accompanies  the  inner  sesamoid  bone  to  the  inner  side  of  the 

»  Esmarch  :  Berlin,  kliu.  Wochenschrift,  1876,  p.  629,  first  case. 


DISLOCATIONS  OF  THE  THUMB  AND  FINGERS. 


795 


metacarpal;  occasionally  it  passes  to  the  outer  side  of  the  metacarpal 
bone,  accompanying  the  external  sesamoid,  but  probably  it  does  so  only 
when,  in  the  production  of  the  dislocation,  the  thumb  is  bent  to  the 
outer  side  as  well  as  backward.     The  head  of  the  metacarpal  bone 


Fig.  441. 


Simple  complete  dislocation;  outer  side.     (Farabeup.) 

projects  through  the  rent  in  the  capsule,  and  the  tendons  of  the  adduc- 
tor, abductor,  and  the  two  portions  of  the  flexor  brevis  rest  against  its 
sides.  The  phalanx  stands  erect  upon  the  dorsum  of  the  metacarpal 
bone,  being  held  there  by  the  tension  of  the  abductor  and  adductor. 


Fig.  442. 


Fig.  443. 


Simple  complete  dislocation;  right 
thumb.  The  long  flexor  tendon  is  dis- 
placed to  the  inner  side.     (Farabeup.) 


Simple  complete  dislocation.      (Farabeup.) 


The  dislocation  is  sometimes  made  compound  by  the  rupture  of  the 
soft  parts  on  the  palmar  aspect  of  the  joint. 

The  appearance  of  the  member  is  characteristic  (Figs.  443  and  444). 
The  phalanx  is  thrown  back  vertically  upon  the  metacarpal  bone, 
and  the  latter  is  adducted,  the  thenar  eminence  being  consequently 


796 


DISLOCATIONS. 


increased  in  thickness  and  diminished  in  breadth.  The  head  of  the  meta- 
carpal bone  projects  in  front  as  a  round,  smooth  prominence  close  under 
the  skin,  over  which  the  tendon  of  the  long  flexor  may  perhaps  be  felt. 
The  phalanx  is  quite  movable  from  side  to  side,  and  can  be  rotated ;  it 
can  also  be  turned  down  so  as  to  be  parallel  with  the  metacarpal  bone,  but 
this  movement  should  be  avoided  lest  it  produce  the  condition  to  which 
Farabeuf  gave  the  name  of  complex  form,  the  essential  feature  of  which 
he  thought  to  be  the  interposition  of  the  sesamoid  bones  between  the 
phalanx  and  metacarpal,  and  which  presents  great  difficulty  of  reduc- 
tion. The  cause  of  this  difficulty,  in  all  the  cases  in  which  I  have 
exposed  the  joint,  has  been  the  torn  edge  of  the  anterior  ligament 
closely  drawn  across  the  back  of  the  metacarpal  behind  its  head,  and 
a  slight  nicking  of  that  edge  made  reduction  easy.     It  is  believed  that 

Fig.  444. 


Fresh  dorsal  dislocation  of  the  thumb. 


flexion  of  the  dislocated  phalanx  tends  to  produce  this  engagement  of 
the  capsule,  but  I  know  that  it  can  take  place  without  that  aid. 

Treatment.  The  attitude  of  the  thumb  is  maintained  by  the  tension 
of  the  short  muscles  attached  to  it,  and  all  that  is  necessary  to  over- 
come that  opposition  is  to  relax  the  muscles  by  pressing  the  metacar- 
pal bone  toward  the  palm  ;  then  reduction  is  made,  while  maintaining 
the  phalanx  in  rectangular  dorsal  flexion,  by  pressing  its  base  down- 
ward toward  the  end  of  tlie  metacarpal  and  flexing  when  the  proper 
level  is  reached.  If  the  torn  anterior  ligament  has  not  caught  behind 
the  head,  as  just  described,  it  will  be  pushed  before  the  base  of  the 
plialanx  and  the  latter  will  turn  past  the  head  of  the  metacarpal  in 
flexion  as  soon  as  it  descends  far  enough. 


DISLOCATIONS  OF  THE  THUMB  AND  FINGEHS. 


■97 


If,  on  the  other  hand,  the  ligament  has  caught  above  tlie  head  it 
becomes  a  serious  obstacle ;  it  may  sometimes  be  freed  by  rotating  the 
phalanx  while  pressing  it  downward  as  just  described,  and  the  bone  has 
sometimes  been  got  into  place  by  forcible  traction  in  straight  extension. 
The  latter  is  probably  only  accomplished  after  the  traction  has  torn  the 
attachments  sufficiently  to  permit  the  phalanx  to  be  drawn  quite  away 

Fig.  445. 


Complex  dislocation  of  the  thumb  ;  outer  side.    The  hook  raises  the  periosteal  continuation  of 
the  lateral  ligament,  exposing  the  reflected  and  interposed  capsule.    (Farabeuf.) 

from  the  metacarpal,  and  I  think  the  plan  is  distinctly  inferior  to  an 
open  arthrotomy. 

In  reduction  by  arthrotomy  the  incision  is  made  longitudinally  along 
the  projection  of  the  head  of  the  metacarpal ;  as  soon  as  this  is  exposed 
the  sides  of  the  incision  are  drawn  apart  and  the  torn  edge  of  the  liga- 
ment, which  can  be  distinctly  seen  above  it  somewhat  as  in  Fig.  442,  is 

Fig.  446. 


Complex  dislocation.    (Farabeuf.) 

nicked  at  its  centre  ;  the  dislocation  is  then  easily  reduced.'  I  presume 
the  nicking  might  be  done  Avithout  a  long  incision,  by  passing  in  a 
tenotome.  In  some  cases  it  has  been  sufficient  to  lift  the  long  flexor 
tendon  around  to  the  front  from  the  side  of  the  head,  which,  I  presume, 
is  efficient  because  the  tendon  is  attached  to  the  capsule  and  brings  it 
with  it  in  the  movement. 

The    prognosis    in    the  past   has   not  been    favorable.      Polaillon,^ 

1  Stimson  :  New  York  Medical  .lonrnal,  March  Sn.  1889. 

2  Polaillon  :  Diet.  Eucyclopedique  des  Sc.  Med.,  art.  Doigt. 


798  DISLOCATIONS. 

analvzing  58  cases,  found  that  reduction  had  failed  in  11  and  had  been 
effected  only  after  numerous  and  prolonged  attempts  in  16  ;  in  8  the 
dislocation  was  compound,  and  in  3  of  these  the  head  of  the  metacar- 
pal bone  was  excised.  In  one  case  (Bromfield),  nearly  a  hundred 
years  ago,  such  violent  traction  was  made  that  the  terminal  phalanx 
was  torn  oflF;  the  case  has  been  persistently  quoted  as  a  warning  ever 
since,  but  if  it  is  remembei'ed  that  traction  is  especially  ill-adapted  to 
effect  reduction  in  difficult  cases  the  warning  will  not  be  longer  needed. 
In  other  cases  the  thumb  has  become  gangrenous  in  consequence  of 
the  violence  inflicted  upon  it  by  the  traction. 

In  the  cases  in  which  the  dislocation  has  been  left  unreduced  and 
the  phalanx  has  been  lowered  to  a  position  in  which  it  is  parallel  with 
the  metacarpal  bone,  the  usefulness  of  the  member  has  been  in  great 
part  restored,  although,  of  course,  the  deformity  persisted  and  the  joint 
was  immovable. 

Forward  Dislocations. 

These  dislocations,  much  rarer  than  the  preceding  and  less  difficult 
to  reduce,  result  usually  from  a  fall  or  blow  upon  the  back  of  the 
flexed  phalanx — that  is,  by  exaggerated  palmar  flexion,  but  in  at  least 
one  case  (Lombard)  from  exaggerated  dorsal  flexion  presumably  com- 
bined with  direct  impulsion  of  the  phalanx  toward  the  palm ;  accord- 
ing to  Foucart's^  experiments  dorsal  flexion  needed  to  be  combined 
with  forced  abduction  in  order  to  rupture  the  internal  lateral  ligament. 

Pathology.  The  pathology  has  been  shown  by  six  autopsies,  AVood,^ 
Meschede,^  Foucart,  two  cases.  Eve/  and  one  of  my  own  not  before 
reported.  In  two  of  these  (Foucart,  Eve)  the  injury  was  recent;  in 
Mesched^'s  it  had  .lasted  forty-eight  days ;  and  in  Foucart's  second 
case,  in  Eve's,  and  in  mine  it  was  of  long  standing.  The  recent  cases 
show,  as  is  also  found  in  experiments  upon  the  cadaver,  that  the  pos- 
terior and  lateral  parts  of  the  capsule  are  torn,  including  the  lateral 
ligaments,  but  that  the  connection  between  one  or  both  sesamoid  bones 
and  the  metacarpal  bone  may  persist.  The  extensor  tendons  may  be 
stretched  directly  over  the  projecting  head  of  the  metacarpal  bone  or 
they  may  be  deviated  to  either  side ;  in  my  case  the  tendon  of  the 
extensor  primi  internodii  appeared  to  have  been  detached  and  retracted. 
The  base  of  the  phalanx  lies  against  the  anterior  surface  of  the  meta- 
carpal bone,  and,  in  recent  cases  at  least,  does  not  appear  to  be  notably 
displaced  upward  ;  it  may  lie  directly  in  front,  or  be  somewhat  dis- 
placed to  either  side,  and  the  phalanx  may  be  in  straight  extension  or 
partly  flexed. 

In  the  older  cases  a  more  or  less  complete  nearthrosis  forms  between 
the  bones,  and  fibrous  bands  and  bony  outgrowths  give  the  joint  suffi- 
cient solidity  to  make  it  useful. 

Symptoms.     The  deformity  is  characterized  by  the  position  of  the 

1  Foucart :  These  de  Paris,  1876,  No.  199,  quoted  by  Poinsot. 

2  Wood :  Transactions  Pathological  Society  of  London,  1853,  vol.  iv.  p.  250. 

*  Meschede  :  Virchow's  Archiv,  1866,  vol.  xxxvii.  p.  510. 

*  Eve:  Lancet,  1880,  vol.  i.  p.  133. 


DISLOCATTONS  OF  THE  THUMB  AND  FINGERS.  799 

})halaux  iu  front  of  the  metacarpal  bone,  the  projection  of  the  head  of 
the  latter  on  the  dorsum  of  the  member,  and  the  rather  deeply  placed 
prominence  formed  by  the  base  of  the  phalanx  at  the  lower  part  of  the 
thenar  eminence.  The  thumb  appears  in  some  cases  to  have  undergone 
slight  rotation  about  its  long  axis,  and  the  attempt  has  been  made  to 
show  a  connection  between  the  direction  of  this  rotation  and  that  of 
the  lateral  displacement  of  the  extensor  tendons ;  that  is,  it  has  been 
claimed  that  when  the  rotation  is  such  that  the  nail  looks  outward  the 
tendons  have  been  displaced  toward  the  outer  side,  and  vice  versa. 

In  one  reported  case  the  dislocation  was  made  compound  by  rupture 
of  the  soft  parts  covering  the  back  of  the  joint ;  recovery  was  delayed 
by  a  phlegmon  of  the  ball  of  the  thumb. 

Treatment.  Reduction  is  generally  easy,  and  is  effected  either  by 
traction  and  coaptation,  or,  better,  by  forced  flexion  of  the  thumb 
aided,  if  necessary,  by  impulsion  downward  of  its  base.  This  latter 
method  is  analogous  to  that  recommended  in  the  treatment  of  the 
dorsal  variety,  but  there  is  not  the  same  urgent  reason  for  it  that  arises 
in  the  latter  from  the  relations  of  the  capsule.  If  any  difficulty  should 
arise  from  the  tension  of  the  displaced  extensor  tendons  the  phalanx 
should  be  inclined  toward  the  side  on  which  they  lie  before  making 
the  usual  manoeuvre. 

Lateral  Dislocations. 

Bessel-Hagen  ^  reports  a  unique  case  of  dislocation  to  the  ulnar  side. 
The  patient  was  twenty-eight  years  old  ;  the  injury  was  caused  appar- 
ently by  forcible  bending  of  the  thumb  toward  the  opposite  side. 
Reduction  by  traction  and  pressure. 

METACARPOPHALANGEAL  DISLOCATIONS  OF  THE  FINGERS. 

The  shallow  cavity  formed  by  the  articular  surface  of  the  base  of  the 
proximal  phalanx  is  deepened  by  the  thick  anterior  portion  of  the  cap- 
sule, which  forms,  as  in  the  thumb,  a  stout  transverse  band  or  apron 
which  accompanies  the  phalanx  in  its  displacement,  and  may  in  like 
manner  become  interposed  between  the  bones  in  a  backward  disloca- 
tion. The  resemblance  is  still  further  increased  by  the  occasional  devel- 
opment of  a  sesamoid  bone  in  this  ligament,  especially  at  the  index- 
finger  ;  its  next  most  frequent  appearance  is  at  the  little  finger. 

Dislocations  of  the  proximal  phalanges  of  the  fingers  are  much  less 
frequent,  even  when  taken  together,  than  those  of  th^:  thumb ;  and 
those  of  the  index-finger  are  more  frequent  than  those  Oi  *be  other 
three  fingers.  Of  28  cases  collected  by  Polaillon,  the  dislocation  in 
17  was  backward,  in  10  forward,  in  1  not  given  ;  15  were  of  the  index- 
finger,  4  of  the  middle,  and  3  each  of  the  ring  and  little  fingers;  in 
2  adjoining  fingers  were  dislocated,  and  in  1  all  four. 

»  Bessel-IItigen  :  Arch,  fiir  klin.  Chir.,  1888,  p.  386. 


800  DISLOCATIONS. 

Backward  Dislocations. 

The  common  cause  is  hvperextension  (dorsal  flexion)  of  the  finger. 
Experiment  upon  the  cadaver  and  direct  observation  in  compound  dis- 
locations or  after  arthrotomy  in  irreducible  ones^  show  that  the  rupture 
of  the  capsule  takes  place  in  front  along  its  attachment  to  the  meta- 
carpal bone.  In  a  case  reported  by  Willemer  ^  the  dislocation  was 
irreducible  by  manipulation,  and  Konig  resorted  to  arthrotomy, 
making  an  incision  on  the  ulnar  side  of  the  palmar  surface  of  the  joint 
(index-finger) ;  he  found  the  anterior  portion  of  the  capsule  had  been 
drawn  back  past  the  articular  surface  of  the  phalanx  so  that  it  was 
completely  interposed  between  the  two  bones,  and  that  a  sesamoid  bone 
was  developed  on  it.  This  makes  the  case  strictly  analogous  to  the 
complete  form  of  backward  dislocation  of  the  thumb,  and  corroborates 
the  opinion  that  the  cause  of  the  irreducibility  in  the  latter  is  to  be 
found  in  the  position  of  the  torn  anterior  ligament  rather  than  in  the 
tension  of  the  tendons  of  the  short  muscles. 

Lange  ^  says  of  his  case  :  "  The  smallest  possible  cord  of  the  capsule, 
which  was  torn  from  its  attachment  to  the  metacarpus,  had  interposed 
itself  like  an  apron  between  the  dorsum  of  the  metacarpus  and  the 
border  of  the  articular  plane  of  the  phalanx.  .  .  .  He  was  obliged 
to  incise  and  draw  outward  the  light  lateral  parts  of  the  capsule, 
when  reduction  was  effected  without  difficulty.  A  fair  result  was 
obtained." 

A  similar  condition  was  observed  in  a  case  upon  which  Volkmann^ 
operated  in  like  manner  with  a  good  result,  and  in  one  of  my  own. 

The  symptoms  are  the  prominence  of  the  base  of  the  phalanx  on  the 
dorsum  of  the  hand,  and  that  of  the  head  of  the  metacarpal  bone  in 
the  palm,  more  or  less  shortening  of  the  finger,  and  loss  or  diminution 
of  function.  The  finger  may  be  extended  or  slightly  flexed  upon  the 
metacarpus ;  in  one  case  the  first  phalanx  was  in  rectangular  dorsal 
flexion.  The  middle  and  distal  phalanges  are  straight  or  slightly 
flexed. 

In  5  of  Polaillon's  17  cases  the  dislocation  was  complicated  by  a 
wound  on  the  palmar  aspect  of  the  joint  through  which  the  head  of 
the  metacarpal  bone  projected,  and  in  another  the  skin  was  so  tightly 
stretched  over  the  end  of  the  bone  that  it  threatened  to  slough.  In  2 
cases  reduction  failed  (without  operation),  and  in  5  it  was  difficult,  and 
was  at  last  effected  by  rectangular  dorsal  flexion  of  the  phalanx  and 
direct  impulsion  downward  as  in  backward  dislocation  of  the  thumb. 

Treatment.  If  the  dislocation  is  incomplete  reduction  may  be  easily 
effected  by  moderate  traction  followed  by  flexion,  but  in  the  complete 
cases  it  is  certainly  more  prudent  to  act  as  in  the  similar  dislocations 
of  the  thumb  in  order  more  surely  to  avoid  the  interposition  of  the 
anterior  portion  of  the  capsule. 

'  Wniemer:  Ccntralblatt  fiir  Chirurgie,  1883,  p.  566. 

2  Lange:  New  York  :\rt(lical  Eecord,  1879,  p.  100. 

^Volkmann  :  Reported  by  Eanke,  Berlin,  klin.  Wochenschrift,  1877,  p.  524. 


DISLOCATIONS  OF  THE  THUMB  AND  FINGERS.  SOI 

Forward  Dislocations. 

The  cause,  except  in  an  incomplete  case  observed  by  Malgaigne, 
has  always  been  notable  violence  received  upon  the  finger,  usually  in  a 
fall,  but  the  mode  of  production  is  not  clear.  Malgaigne's  patient  was 
a  shoemaker  and  caused  the  dislocation  by  turning  in  his  hand  the 
shoe  upon  which  he  was  at  work. 

The  symptoms  are  the  presence  of  the  base  of  the  phalanx  in  the 
])alm  and  the  projection  of  the  head  of  the  metacarpal  bone  at  the 
back  of  the  hand.  The  finger  is  extended  or  slightly  flexed,  and 
appears  usually  to  be  deviated  to  one  or  the  other  side,  sometimes  very 
markedly,  with  displacement  of  the  extensor  tendons  toward  the  same 
side.  Reduction  has  been  effected  by  traction  and  coaptative  pressure. 
Possibly  flexion  would  be  eflicient  in  the  more  difficult  cases,  as  in  the 
similar  dislocations  of  the  thumb. 

DISLOCATIONS  OF  THE  MIDDLE  PHALANGES. 

These  dislocations  may  be  backward,  forward,  or  lateral. 

Backward. 

The  usual  cause  is  a  fall  upon  the  palmar  surface  of  the  extended 
finger,  which  produces  the  dislocation  by  hyperextension  of  the  phalanx 
and  sometimes  ruptures  the  skin  over  the  front  of  the  joint.  The 
phalanx  may  remain  hyperextended  upon  the  proximal  one,  even  to  a 
right  angle,  or  may  be  lowered  so  that  its  axis  is  parallel  to  that  of  the 
other.  The  diagnosis  is  readily  made  by  examination  of  the  relations 
of  the  bones,  and  ordinarily  reduction  is  easily  made  by  direct  impul- 
sion of  the  hyperextended  phalanx  or  by  traction  and  flexion.  The 
anterior  portion  of  the  capsule  resembles  that  of  the  metacarpo-pha- 
langeal  joints  in  being  thick  and  rigid,  and  it  is  quite  possible,  there- 
fore, that  it  may  become  interposed  as  above  described  and  make 
reduction  difficult  or  impossible,  as  in  a  case  treated  by  Polaillon  ^  in 
which  all  measures  failed.  It  seems  advisable,  therefore,  that  the  first 
trial  should  be  of  direct  impulsion  upon  the  hyperextended  phalanx, 
and,  this  failing,  the  phalanx,  still  extended,  should  be  pressed  bodily 
toward  the  side  on  which  the  flexor  tendons  may  be  displaced  and  then 
rotated  so  as  to  carry  the  tendons  forward  past  the  head  of  the  other 
phalanx. 

Forward. 

These  may  be  complete  or  incomplete,  according  to  the  extent  to 
which  the  base  of  the  middle  phalanx  is  displaced  upward  along  the 
palmar  aspect  of  the  proximal  one.  The  symptoms  are  the  well- 
marked  prominence  of  the  head  of  the  first  phalanx  on  the  back,  and 
the  less  marked  projection  of  the  base  of  the  second  phalanx  on  the 
palmar  surface  when  it  is  extended.     With  the  displacement  upward 

'  Polaillon:   Loc.  cil.,  p.  184. 


802  DISLOCATIONS. 

may  be  associated  some  lateral  displacement  or  a  lateral  deviation  of 
the  axis  of  the  second  phalanx. 

Reduction  is  easily  made  by  traction  and  coaptative  pressure,  but  in 
an  old  case  treated  by  Hamilton  the  effort  had  failed,  and  in  one  treated 
by  Thorens  the  aid  of  anaesthesia  was  necessary. 

Lateral. 

Of  these  but  few  cases  have  been  reported ;  Polaillon  could  collect 
only  eight,  of  which  the  dislocation  w^as  to  the  inner  side  in  seven,  and 
to  the  outer  side  in  one.  In  a  case  quoted  by  him  from  Ch6dan  the 
middle  phalanges  of  the  last  three  fingers  were  simultaneously  dislo- 
cated toward  the  inner  side,  forming  almost  a  right  angle  with  the  side 
of  the  first  phalanx.  Duplay,i  who  saw  a  case,  says  "  the  dislocated 
phalanx  is  markedly  deviated  inward  so  as  to  form  almost  a  right  angle 
and  to  cross  the  course  of  the  adjoining  finger.  At  the  apex  of  the 
angle  the  lower  end  of  the  first  phalanx  can  be  felt ;  the  dislocated 
phalanx  projects  on  its  inner  side." 

In  Eollet's  case  of  dislocation  to  the  outer  side  the  base  of  the  second 
phalanx  of  the  ring  finger  projected  upon  the  outer  side  of  the  first 
phalanx  ;  the  second  phalanx  was  somewhat  inclined  inward,  and  the 
distal  phalanx  was  slightly  flexed.  The  shortening  was  about  two- 
thirds  of  a  centimetre. 

In  two  of  the  eight  cases  the  dislocation  was  compound,  but  the 
patients  recovered  without  anchylosis. 

Reduction  was  easily  effected  in  every  case  by  traction  and  coaptation. 

DISLOCATIONS    OF    THE    DISTAL    PHALANGES. 

These  dislocations  may  be  backward,  forward,  or  lateral,  the  former 
being  by  far  the  most  frequent ;  forward  dislocations  have,  I  believe, 
been  encountered  only  in  the  thumb. 

Backward. 

Backward  dislocation  of  the  distal  phalanx  is  commonly  caused  by 
a  fall  or  blow  upon  the  end  of  the  outstretched  finger.  The  disloca- 
tion may  be  complete  or  incomplete,  simple  or  compound,  and  it  may 
be  directly  backward  or  backward  and  to  one  side. 

The  anterior  ligament  is  torn  away  from  one  or  the  other  bone,  in 
the  thumb  usually  from  the  proximal  phalanx,  in  the  fingers  from  the 
distal  one.  The  lateral  ligaments  remain  intact,  unless  the  dislocation 
is  to  one  side  as  well  as  backward.  The  flexor  tendon  may  be  torn 
away  from  its  attachment,  or  it  may  be  displaced  to  one  side. 

Reduction  is  usually  easy,  but  may  be  made  difficult  by  interposition 
of  the  anterior  portion  of  the  capsule  when  this  accompanies  the  distal 
phalanx  or  by  the  tension  of  the  displaced  tendon.  In  several  com- 
j)ound  cases  of  the  thumb  the  obstacle  created  by  the  tendon  was  clearly 
demonstrated  and  was  overcome  by  drawing  the  tendon  aside  with  a 
blunt  hook  or  dividing  it. 

1  Duplay :  Pathologic  Externe,  vol.  iii.  p.  332. 


DISLOCATIOXS  OF  THE  THUMB  AND  FINGERS.  803 

The  phalanx  may  be  hyperextended,  or  straight,  or  flexed  across  the 
end  of  the  proximal  one.  '  The  coexistence  of  a  wound  on  the  palmar 
surface  of  the  joint  is  frequent,  thirty-two  times  in  fifty-five  cases  col- 
lected by  Polaillon,  and  has  led  to  very  serious  consequences,  anchy- 
losis, gangrene,  su])puration  extending  to  the  forearm,  tetanus. 

Although  ordinarily  of  easy  reduction,  yet  in  one-quarter  of  Polail- 
lon's  cases  reduction  failed.  As  his  list  is  made  up  largely  of  reported 
cases  it  undoubtedly  contains  an  exceptionally  large  proportion  of  diffi- 
cult and  complicated  ones,  but  still  the  number  of  failures,  thirteen,  is 
large  enough  to  indicate  that  reduction  may  often  require  much  care 
and  skill.  The  principles  controlling  it  are  the  same  as  in  the  back- 
ward dislocations  of  the  other  joints,  and  although  simple  traction 
has  often  sufficed  it  is  prudent  to  refrain  from  it  and  to  reduce  by 
direct  impulsion  of  the  hyperextended  phalanx,  especially  at  the 
thumb.  In  one  case  Hamilton  divided  the  lateral  ligaments  subcuta- 
neously. 

Forward. 

These  dislocations  have  been  observed  only  at  the  thumb,  and  in  a 
large  proportion  of  the  reported  cases  they  have  been  made  compound 
by  a  wound  on  the  palmar  surface.  The  cause,  in  the  few  reported 
cases,  has  been  a  blow  upon  the  end  of  the  phalanx  by  which  it  was 
forcibly  hyperextended.  In  some  cases  the  phalanx  remained  in  this 
position,  its  dorsal  surface  resting  against  the  articular  face  of  the 
proximal  phalanx,  and  its  base  projecting  on  the  palmar  surface ;  in 
other  cases  the  phalanx  was  slightly  flexed,  and  its  base  displaced 
upward  along  the  anterior  surface  of  the  proximal  one. 

Reduction  has  usually  been  easy  by  traction  or  direct  pressure. 

Lateral. 

These  dislocations,  of  which  only  four  or  five  have  been  reported, 
have  been  caused  by  falls,  by  a  kick,  and  by  violently  shaking  the 
hand  while  grasping  it  by  the  end  of  the  finger.  The  phalanx  may 
preserve  its  parallelism  with  the  other,  being  simply  displaced  upward 
along  its  side,  or  it  may  form  a  lateral  angle  with  it,  its  base  resting 
against  the  side  of  the  other.  In  Gogue's  case,  quoted  by  Malgaigne, 
there  was  a  transverse  wound  fifteen  millimetres  long  through  which 
the  head  of  the  middle  phalanx  protruded.  In  Duges's  case  reduction 
was  not  attempted  ;  in  the  others  it  was  easy. 


CHAPTER  L. 

DISLOCATIONS    OF  THE    PELVIS.       DISLOCATIONS    OF    THE 

COCCYX. 

The  union  of  the  two  innominate  bones  at  the  symphysis  pubis  is 
by  a  solid  fibro-cartilaginous  band,  and  without  an  articular  cavity, 
and  the  rupture  of  this  band,  or  its  separation  from  one  or  the  other 
bone,  belongs  more  properly  among  fractures  than  among  dislocations. 
Between  the  articular  surfaces  of  the  ilium  and  sacrum  there  is  usually 
an  articular  cavity,  but  it  is  often  more  or  less  obliterated  by  fibrous 
union  between  the  opposed  cartilaginous  surfaces.  Pure  separations 
at  these  points  without  fracture  are  rare,  and,  except  at  the  pubic  sym- 
physis, hardly  to  be  diagnosticated  with  certainty  during  life.  The 
reader  is,  therefore,  referred  for  most  that  pertains  to  the  subject  to  the 
chapter  upon  fractures  of  the  pelvis. 

Malgaigne  described  the  lesions  as  dislocations,  and  most  writers  have 
followed  his  example.     His  classification  is  as  follows  : 

Dislocations  of  the  pubic  symphysis. 

Dislocations  of  the  sacro-iliac  symphysis. 

Dislocations  of  these  two  symphyses,  or  of  the  ilium. 

Dislocations  of  the  two  sacro-iliac  symphyses,  or  of  the  sacrum. 

Dislocations  of  the  three  symphyses,  or  of  the  three  bones  simulta- 
neously. 

Dislocations  of  the  coccyx. 


DISLOCATIONS    OF   THE   COCCYX. 

The  systematic  descriptions  of  dislocations  of  the  coccyx  which  are 
given  by  the  earlier  writers  were  called  in  question  by  those  of  the  first 
half  of  the  present  century,  some  of  whom,  especially  Boyer,  went  so 
far  as  to  deny  that  the  lesion  had  ever  occurred.  Malgaigne,  however, 
collected  six  cases  of  dislocation  forward,  and  described  a  backward 
form  on  the  authority  of  Lauverjat.  To  these  six  may  be  added  four 
that  have  been  since  reported,  Roeser,^  Bonnefont,^  two  cases,  and 
Mouret,^  the  first  of  which  is  an  example  of  a  variety,  lateral  disloca- 
tion, that  has  not  heretofore  been  described.  It  must  further  be  said 
that  many  cases  have  been  encountered  and  reported  in  which  a  group 
of  symptoms  identical  with  those  observed  in  cases  reported  as  dislo- 
cations, and  following  similar  accidents,  fiills,  blows  upon  the  anal 
region,  has  been  presented,  and  the  conclusion  seems  to  be  unavoid- 
able, either  that  dislocations  or  fractures  of  the  coccyx  are  much  more 

1  Roeser:  Froriep's  Notizen,  1857,  vol.  ii.  No.  10.    Abstract  in  Brit,  and  For.  Med.  Chir. 
Eev.,  1857,  vol.  xx.  p.  414. 

2  Roiinefont:  Union  Medicale,  1859,  vol.  i.  p.  136. 

'  Mouret :  Eec.  de  Mem.  de  Med.  Chir.  et  Pharm.  militaires,  1859,  vol.  i.  p.  350. 

(804) 


DISLOCATIONS  OF  THE  COCCYX.  805 

frequent  than  the  number  of  reported  eases  indicates,  or  that  the  prom- 
inent symptoms  which  accompany  the  recognized  cases,  the  excessive 
pain,  disability,  and  general  nervous  disturbance,  are  due  to  something 
else  than  the  displacement  of  the  bone.  Against  the  latter  alternative 
may  be  urged  the  immediate  relief  and  prompt  recovery  which  have 
followed  the  reduction  of  the  displacement.  Six  cases  in  which  the 
general  symptoms  were  similar  to  those  of  dislocation,  but  in  which  no 
displacement  was  recognizable,  are  reported  by  Warren,'  and  Mouret's 
case  may  perhaps  be  classed  with  them. 

Of  eight  of  the  above  cases  in  which  the  sex  is  noted,  six  were 
women, "and  two  men;  all  were  adults;  and  the  obscure  injury  just 
referred  to,  in  which  the  symptoms  are  the  same,  except  that  no  dis- 
placement is  recognizable,  is  also  much  more  frequent  in  women  than 
in  men. 

Dislocations  Forward. 

The  usual  cause  is  violence  received  upon  the  region  of  the  coccyx 
in  a  fall  upon  the  buttocks  or  astride  a  bar,  or  by  the  breaking  of  a 
chamber  upon  which  the  patient  was  sitting.  The  two  men,  Ravaton, 
Mouret,  were  injured  while  on  hoi-seback,  one  of  them  suddenly  in 
jumping  a  ditch,  the  other  without  special  cause  or  incident,  the  pain 
coming  on  gradually,  and  increasing  for  twenty-four  hours,  and  then 
suddenly  becoming  very  severe  after  a  slight  change  of  position,  with 
a  sensation  of  something  slipping  in  the  rectum. 

The  pain  at  the  moment  of  the  accident  is  so  severe  as  sometimes  to 
cause  the  patient  to  faint ;  there  is  pain  in  defecation,  and  frequent  calls 
to  urinate.  The  pain  radiates  down  the  thighs,  and  sometimes  over 
the  trunk,  head,  and  arms ;  the  patient  is  unable  to  sit  up,  and  the 
slightest  movement  may  greatly  increase  the  suffering.  Coughing  and 
sneezing  and  sometimes  even  every  act  of  inspiration  increase  the  local 
pain.  If  the  condition  remains  unrelieved  (Turner,  a  week  ;  Ravaton, 
seventeen  days ;  Bonnefont,  a  month)  the  general  health  suffers  seri- 
ously, the  patient  becomes  feverish,  and  the  mind  dulled. 

External  examination  may  show  an  ecchymosis  and  swelling  over  the 
situation  of  the  coccyx  and  a  displacement  of  this  bone  forward ;  the 
finger  introduced  into  the  rectum  recognizes  an  angular  displacement  of 
the  coccyx,  in  which  its  point  is  directed  forward,  and  which  is  some- 
times so  great  that  the  bone  stands  almost  at  right  angles  to  its  normal 
position,  and  presses  the  posterior  wall  of  the  rectum  sharply  forward. 

If  now  the  finger  is  hooked  over  the  projecting  end  of  the  coccyx 
it  can  be  readily  drawn  back  into  place,  and  the  reduction  is  followed 
by  immediate,  instantaneous  relief  of  all  the  symptoms.  A  marked 
tendency  to  recurrence  usually  exists  and  may  make  it  necessary  to 
repeat  tlie  reduction  several  times  or  even  to  remove  the  bone.  Re- 
moval of  the  coccyx  after  dislocation  or  fracture,  or  even  when  no 
structural  lesion  could  l)e  detected,  but  the  symptoms  luive  been  severe, 
has  always  given  complete  and  })ermanent  relief  J^ossibly  this  relief 
has  been  (lue  to  division  of  nerves  connected  with  the  coccygeal 
ganglion. 

*  Warren  ;  Singiral  Ohsorvatious,  Boston,  ISGT,  p.  ."!)3. 


806  DISLOCATIONS. 

Dislocation  Backward. 

Dislocation  backward  is  lightly  mentioned  by  some  writers  as  a  not 
infrequent  accident  during  parturition.  Malgaigne  quoted  Lauverjat 
as  follows  :  "  The  considerable  deviation  backward  of  this  bone  some- 
times causes  its  dislocation.  I  have  seen  one  case.  The  patient  suf- 
fered astonishingly,  and  could  not  sit ;  I  reduced  the  coccyx  and  she 
was  immediately  cured." 

Lateral  Dislocation. 

Of  this  only  one  case,  Roeser,  has  been  reported.  The  patient,  a 
large,  corpulent  woman,  thirty-six  years  old,  fell  astride  the  back  of  a 
chair.  She  at  once  suffered  severe  pain  in  the  coccygeal  region,  much 
aggravated  by  attempts  to  sit,  but  she  was  able  to  go  about  for  some 
hours.  At  last  the  pain  became  so  severe  that  she  took  to  her  bed, 
when  she  found  she  could  neither  move  nor  turn.  When  seen  the  next 
day  there  was  so  much  immobility  and  stiffness  of  the  body  as  to  sug- 
gest tetanus.  Besides  the  severe  pain  in  the  coccygeal  region  she  com- 
plained of  a  painful,  tense,  dragging  sensation,  extending  up  toward 
the  nape,  and  along  the  arms  to  the  fingers,  which  felt  numb.  She 
could  not  bear  to  make  the  slightest  movement.  The  head  was  con- 
fused, and  the  intellect  somewhat  clouded.  No  unnatural  sensation  in 
the  lower  limbs ;  urine  and  feces  were  passed  naturally. 

A  small  swelling  was  felt  on  the  left  side  of  the  fissure  of  the  but- 
tocks, which  proved  to  be  the  coccyx  torn  away  from  the  sacrum,  and 
carried  toward  the  left  ischium.  The  end  of  the  sacrum  from  which 
it  had  been  displaced  could  be  plainly  felt.  The  finger  in  the  rectum 
showed  the  exact  nature  of  the  displacement  still  better,  and  when  firm 
pressure  was  made  downward  and  to  the  right  against  the  displaced 
bone,  it  suddenly  resumed  its  normal  position.  The  patient  declared 
she  immediately  felt  quite  another  being,  the  confusion  of  the  head  and 
painful  sensation  along  the  spine  and  arms  disappearing.  At  the  end 
of  the  fifth  day  no  inconvenience  beyond  a  slight  burning  pain  near 
the  sacrum  remained. 

The  severity  of  the  symptoms  in  all  these  forms  appears  to  be  due 
to  a  special  sensitiveness  of  the  region  which,  as  has  been  said,  is  mani- 
fested by  similar  symptoms  associated  with  no  traumatism  or  local 
change,  or,  as  in  a  case  of  my  own,  only  with  a  dry  arthritis  of  the 
joint.  The  removal  of  the  coccyx  in  the  non-traumatic  cases  (coccy- 
godynia)  gives  great  relief. 


CHAPTER   LI. 

DISLOCATIONS  OF  THE  HIP. 

Anatomy — Statistics — Cases   of   Compound  Dislocations — Classification — Back- 
ward Dislocations  :  Dorsal,  everted  dorsal,  anterior  oblique. 

Anatomy. 

The  bony  constituents  of  the  hip-joint  are  the  acetabulum,  or  cot- 
yloid cavity  of  the  os  innominatum,  and  the  globular  head  of  the  femur. 
The  former  is  an  almost  hemispherical  cavity,  situated  at  the  junction 
of  the  ilium,  ischium,  and  pubis,  and  formed  by  the  projection  from 
their  outer  surface  of  a  strong  bony  rim,  which  is  especially  thick  and 
prominent  behind  and  above,  and  is  lacking  below  for  nearly  an  inch 
at  the  point  where  the  cavity  adjoins  the  foramen  ovale,  the  cotyloid 
notch.  The  depth  of  the  cavity  is  increased  by  a  fibro-cartilaginous 
rim  set  upon  its  edge,  the  labrum  cartilagineum,  or  cotyloid  ligament, 
which  crosses  the  cotyloid  notch,  and  is  there  termed  the  transverse 
ligament.  The  wall  of  the  cavity  is  thin  at  its  centre  and  lower  part, 
and  is  elsewhere  very  thick  and  strong.  Its  growth  takes  place  at  the 
junction  of  the  three  bones  which  combine  to  form  it,  this  junction 
being  marked  during  the  period  of  growth  by  a  thin  layer  of  conjugal 
cartilage  having  the  shape  of  an  inverted  Y. 

The  head  of  the  femur  is  rather  more  than  half  of  a  sphere,  having 
a  radius  of  about  an  inch,  and  is  so  placed  upon  the  neck  that  rather 
more  than  half  of  its  cartilage-covered  surface  is  in  front  and  above 
(in  the  upright  position)  and  rather  less  than  half  is  behind  and 
below.  At  a  point  a  little  below  that  at  which  a  prolongation  of  the 
long  axis  of  the  neck  would  touch  its  surface  is  a  depression,  within 
which  the  upper  end  of  the  ligamentum  teres  is  attached. 

The  neck  is  directed  inward,  upward,  and  slightly  backward  from 
its  junction  with  the  shaft,  the  angle  which  it  makes  with  the  long 
axis  of  the  latter  being  about  130  degrees.  The  great  trochanter,  con- 
tinuous with  the  outer  surface  of  the  shaft,  overlaps  the  neck  above 
and  behind,  its  highest  part  being  situated  posteriorly  and  curved 
inward ;  the  portion  which  is  most  external  and  most  nearly  subcuta- 
neous is  about  an  inch  below  the  up})er  margin. 

The  capsule  is  attached  above  along  the  entire  periphery  of  the 
cotyloid  cavity,  just  outside  the  free  margin  of  the  labrum  cartilagi- 
neum, and  below  to  the  femur  at  or  near  the  junction  of  the  neck  and 
shaft,  extending  in  front  to  the  inter-trochanteric  line,  above  nearly 
to  the  root  of  the  great  trochanter  in  the  digital  fossa,  behind  to  the 
neck  itself  a  little  short  of  its  outer  limit,  and  below  to  the  upper  part 
of  the  lesser  trochanter.  It  is  comjwsed  of  fibres  arranged  longitudi- 
56  ( S07  ) 


808 


DISLOCATIONS. 


nally  and  circularly,  and  varies  greatly  in  strength  and  thickness  at 
different  points.  Those  portions  which  are  especially  thickened  by 
multiplication  of  the  longitudinal  fibres  are  known  as  accessory  liga- 
ments; of  these  the  strongest  and  most  important  is  the  one  situated 
in  the  anterior  part  of  the  capsule,  and  known  as  the  ilio-femoral  liga- 
ment, or  the  ligament  of  Bertin,  or  Bigelow's  Y-ligament  (Fig.  447). 

This    arises    from    the    anterior 
Fig.  447.  inferior  spine  of  the  ilium,  and 

from  the  surface  of  the  bone 
immediately  behind  it  and  above 
the  edge  of  the  acetabulum,  and 
its  fibres  passing  downward 
diverge  to  form  two  strong 
bands,  of  which  the  inner  passes 
almost  vertically  to  the  lower 
part  of  the  anterior  intertrochan- 
teric line,  and  the  outer  to  the 
upper  part  of  the  same  line. 
Ihe  ligament  is  about  one-fourth 
of  an  inch  thick  at  its  thickest 
part,  and  is  very  strong,  perhaps 
the  strongest  in  the  body,  and 
will  sustain  without  rupture  a 
strain  of  from  250  to  750  pounds 
(Bigelow).  Its  inner  portion  is 
especially  concerned  in  limiting 
extension  of  the  limb;  its  outer 
portion  in  limiting  e version. 

The  other  thickened  portions 
of  the  capsule  are  those  known 
as  the  pubo-femoral  and  ischio- 
femoral ligaments;  the  former 
arises  from  the  anterior  and  in- 
ferior portion  of  the  acetabular  margin  and  the  pubis  as  far 
inward  as  the  pectineal  eminence,  and  extends  in  the  anterior  and 
lower  part  of  the  capsule  to  its  insertion  above  the  small  trochanter. 
The  ischio-femoral  ligament  is  a  strong  band  of  fibres  on  the  outer 
and  posterior  portion  of  the  capsule,  arising  from  the  groove  on  the 
ischium  below  the  acetabulum.  The  pubo-femoral  ligament  limits 
abduction;  the  ischio-femoral  limits  inversion.  On  each  l."-'^  of  the 
pubo-femoral  band  the  capsule  is  very  thin;  outside  and  Lvxiind  the 
Y-ligament  the  capsule  is  very  strong,  limiting  adduction  and  inward 
rotation  (Bigelow). 

The  joint  is  thickly  covered  in  by  muscles,  of  which  it  is  desirable 
here  to  mention  only  one,  the  obturator  internus,  which  plays  an 
important  part  in  the  backward  dislocations.  This  muscle,  arising 
from  the  inner  surface  of  the  obturator  foramen  and  the  surface  of 
bone  between  it  and   the  great  sacro-sciatic  notch,  passes  outward 


The  iliofemoral,  or  Y-ligament.     (Bigelow.) 


DISLOCATIONS  OF  THE  HIP.  809 

through  the  small  sacro-sciatic  notch,  turns  sharply  forward,  and  is 
inserted  upon  the  front  part  of  the  inner  surface  of  the  great  trochanter 
in  conjunction  with  the  two  gemelli  which  arise  respectively  from  the 
spine  and  tuberosity  of  the  ischium.  Above  it  is  the  pyriformis,  below 
it  the  quadratus  femoris. 

The  centre  of  the  head  of  the  femur  lies  about  two  inches  directly 
below  the  anterior  inferior  spine  of  the  ilium,  and  at  about  the  same 
distance  downward  and  outward  from  the  centre  of,  and  in  a  direction 
at  right  angles  to,  a  line  drawn  from  the  anterior  superior  spine  of  the 
ilium  to  the  spine  of  the  pubis.  When  the  bones  are  normal  and  in 
place,  and  the  limb  is  partly  flexed,  a  line  drawn  across  the  outer  aspect 
of  the  thigh  from  the  anterior  superior  spine  of  the  ilium  to  the  lowest 
part  of  the  tuberosity  of  the  ischium  will  cross  the  upper  part  of  the 
great  trochanter.  This  is  known  as  Nelaton's,  or  the  ischio-iliac  line  ; 
its  relations  to  the  trochanter  have  great  diagnostic  importance.  In 
the  child,  according  to  Hueter,  the  trochanter  is  brought  somewhat 
higher  by  the  relative  shortness  of  the  neck  of  the  femur. 

Extension  and  abduction  are  checked  in  the  living  by  the  ligaments 
of  the  joint,  flexion  and  adduction  by  the  muscles  or  by  the  contact  of 
the  limb  with  the  abdomen  in  flexion.  The  range  of  abduction  and 
adduction  is  further  modified  by  the  position  of  the  limb  as  regards  its 
flexion  and  its  rotation  about  the  long  axis. 

The  position  of  the  limb  in  which  dislocation  of  the  hip  most 
frequently  occurs  is  that  of  flexion,  adduction,  and  inward  rotation, 
and  the  dislocation  which  then  occurs  is  one  of  the  backward  forms, 
although  after  the  head  of  the  bone  has  left  the  socket  abduction  and 
outward  rotation  of  the  limb  may  lodge  it  in  the  obturator  foramen. 
In  this  position  the  posterior  and  inferior  portion  of  the  capsule  is  put 
upon  the  stretch  and  ruptured.  By  outward  rotation  and  abduction  the 
head  may  be  forced  out  at  the  lower  and  inner  part  of  the  capsule  below 
the  pubo-femoral  ligament,  toward  the  obturator  foramen  ;  in  each  case 
a  new  centre  is  found  for  the  exaggerated  movement  in  the  more  or 
less  direct  contact  between  the  neck  of  the  femur  and  the  margin  of 
the  acetabulum  or  in  the  tension  of  part  of  the  Y-ligament.  The  force 
which  produces  the  dislocation,  therefore,  almost  always  acts  indirectly, 
either  by  moving  the  limb  upon  the  fixed  trunk  or  by  moving  the 
trunk  upon  the  fixed  limb.  In  the  great  majority  of  cases  the 
Y-ligament  remains  untorn,  and  by  the  restraint  which  it  exerts 'upon 
the  movements  of  the  displaced  femur  it  determines  in  a  large  measure 
the  character  of  the  secondary  displacement,  the  attitude  in  which  the 
limb  comes  to  rest,  and  the  manipulations  by  Mdiich  the  dislocation  can 
be  reduced.  This  influence  is  so  great  that  Bigelow  based  upon  it  the 
distinction  which  lie  made  between  "regular"  and  "  irrogulnr "  dis- 
locations, the  former  including  those  cases  in  which  the  ligament 
remained  untorn  and  the  attitude  of  the  limb  was  in  consequence  char- 
acteristic ;  the  latter  those  in  which  the  ligament  was  more  or  less  torn 
and  the  attitude  and  displacement  variable.  The  distinction  has  some- 
times an  important  bearing  upon  the  treatment  and  deserves  to  be 
preserved. 


810  DISLOCATIOyS. 

Statistics. 

The  tables  in  Chapter  XXVII.  show  that  the  percentages  of  dislo- 
cation of  the  hip,  compared  with  all  dislocations,  vary  from  1.4  to  2 
per  cent.  Agnew^  says  that  of  912  dislocations  admitted  to  the 
Pennsylvania  Hospital  89  (9.75  per  cent.)  were  of  the  hip.  Of 
Kronlein's  8  cases  4  were  in  patients  not  more  than  ten  years  old,  and 
of  Prahl's^  41  cases  12  were  of  the  same  age,  8  were  between  eleven 
and  twenty,  and  11  were  between  twenty-one  and  thirty  years  old. 
This  preponderance  in  youth  is,  however,  not  found  in  Agnew's  list  or 
in  the  41  cases  collected  by  Malgaigne  or  the  84  cases  collected  by 
Hamilton.     The  latter  were  divided  as  follows  : 

Under  15  vears  ........  15 

15     to  30  ' "  32 

30     "  45     "  29 

45     "  60     "  7 

60     "  85     "  1 

Agnew's  89  cases  are  thus  divided  : 

15  to  25  years 39 

25  "  35  '"  26 

35  "  45     " 12 

45  "  55     "  6 

55  "  65     "  .5 

65  "  75     "  1 

Although  the  numbers  are  larger  in  Hamilton's  collection  than  in 
Prahl's,  yet,  as  the  latter  are  the  integral  statistics  of  a  single  hospital 
and  dispensary,  I  think  its  percentages  are  more  likely  to  represent  the 
actual  proportions  than  those  of  a  collection  of  published  cases  are. 
I  do  not  know  how  to  account  for  the  absence  from  Agnew's  list  of 
patients  under  fifteen  years  of  age. 

The  earliest  age  at  which  a  dislocation  has  been  reported  is  six 
months  f  it  was  a  dislocation  upon  the  obturator  foramen,  and  was 
caused  by  the  fall  of  a  chair  in  which  the  child  was  tied.  In  the 
report  by  W.  A.  Johnson,*  of  a  clinical  lecture  by  Prof.  Gross,  it  is 
said,  "  upward  of  six  years  ago  this  child,  M.  S.,  aged  seven  years,  had 
a  fall,"  and  received  a  dorsal  dislocation  of  the  hip.  The  note  is 
entitled,  "  Dislocation  of  the  hip-joint  in  a  child  six  months  of  age." 
Bartels^  reported  a  dorsal  dislocation  at  eleven  months  caused  by  the 
effort  made  to  put  on  a  shoe.  Several  others  have  been  reported 
between  the  ages  of  eighteen  months  and  five  years. 

Tlie  oldest  patient  is  one  reported  by  Kennedy,^  a  woman,  aged 
ninety-one  years  and  five  months,  who  received  a  dorsal  dislocation  of 
the  right  hip  by  a  fall,  while  walking  across  a  smooth  floor ;  it  was 
reduced  on  the  twelfth  day  by  inanipulation,  and  two  days  later  the 
patient  died.     The  autopsy  verified  the  diagnosis.     The  next  oldest 

'  Agnew:  Surgery,  vol.  ii.  p.  89. 

2  Prahl :  InaiiK.  Dis.,  Centralbl.  fiir  Cliir.,  1881,  p.  57. 

'  Powdrell :  Lancet,  1863,  vol.  i.  p.  617. 

*  .Johnson  :  Philadelphia  jMedical  Times.  1876-7,  vol.  vii.  p.  5. 

^  Bartels :  Arch,  fiir  kliii.  C'hir..  1874.  vol.  xvi.  p.  6.50. 

^  Kennedy:  Cincinnati  Lancet  and  Clinic,  1878,  vol.  i.  p.  256. 


DISLOCATIOXS  OF  THE  BIP.  811 

patient,  eighty-six  years,  was  also  a  woman,^  and  the  next  a  man 
eighty-one  years  old,  whose  dislocation  "vvas  suprapubic  and  was  veri- 
fied by  autopsy  four  years  later ;  the  neck  of  the  bone  was  broken  by 
an  attempt  to  reduce  while  the  injury  was  recent ;  the  case  was  reported 
by  Verneuil.- 

The  injury  is  much  more  common  in  males  than  in  females;  of 
Agnew's  89  cases,  11  were  women  ;  of  115  cases  collected  by  Hamilton, 
104  were  males. 

Concerning  the  relative  frequency  of  the  different  varieties  it  can  be 
said  that  those  in  which  the  head  of  the  femur  is  found  resting  upon 
the  lower  part  of  the  ilium  behind  the  outer  posterior  half  of  the  ace- 
tabulum, the  so-called  "  iliac  "  dislocation,  to  preserve  for  the  moment 
the  old  classification,  or  still  lower  down  on  the  upper  part  of  the 
ischium,  "  ischiatic  "  dislocations,  are  much  more  frequent  than  those 
in  which  it  rests  in  front  or  on  the  inner  side  of  the  acetabulum,  the 
suprapubic  and  obturator  dislocations.  The  dislocations  upon  the  dor- 
sum of  the  ilium  are  generally  thought,  on  clinical  evidence,  to  be 
more  frequent  than  the  ischiatic,  but  a  comparison  of  the  cases  exam- 
ined after  death  does  not  corroborate  this  view ;  Malgaigne  collected 
10  autopsies  of  ischiatic  dislocations,  and  only  6  of  the  iliac,  one  of 
these  being  primarily  ischiatic,  and  Lossen,^  taking  only  cases  reported 
since  1855,  found  19  ischiatic  and  only  5  iliac.  Probably  Malgaigne's 
supposition  is  correct  that  many  ischiatic  cases  observed  clinically  are 
thought  to  be  iliac  ;  indeed,  it  will  further  appear  that  in  many  "  iliac  " 
dislocations  the  head  of  the  femur  has  primarily  passed  downward  and 
backward,  and  that  its  presence  upon  the  dorsum  of  the  ilium  is  due 
to  a  secondary  displacement  upward.  Roser  goes  so  far  as  to  claim 
that  the  iliac  dislocations,  in  which  the  head  of  the  femur  has  left  the 
cotyloid  cavity  by  its  upper  posterior  portion,  are  the  rarest  of  all  the 
principal  forms.  Of  the  two  anterior  forms  the  obturator  seems  to  be 
more  frequent  than  the  suprapubic,  but  the  reported  cases  are  too  few 
to  justify  a  positive  assertion. 

Simultaneous  dislocation  of  both  hips  has  been  reported  in  about  thirty 
cases  (see  Chapter  LIII.). 

Compound  dislocations  are  very  rare,  as  might  be  expected  from  the 
thickness  of  the  soft  parts  which  everywhere  cover  in  the  joint.  Illus- 
trative cases  are  those  of  Walker,*  Bransby  Cooper,^  Macouchy,** 
Moxon/  a  German  military  surgeon,^  Taylor,^  Woodward,^**  Langmaid 
and  Cabot,  reported  by  Perkins,^^  and  Cheever.^^  In  the  first  case  the 
patient  fell  under  a  wagon,  the  wheel  passing  over  the  back  of  his 
pelvis  and  right  thigh  ;  the  head  of  the  femur  was  forced  "  forward 

1  Gauthier'  Quoted  by  Malgaigne,  loc.  cit.,  p.  805. 

2  Venieuil:  Bull,  de  la  Soc.  de  C'hir.,  1865,  vol.  vi.  p.  495. 
'  Lossen  :   Deutsche  Chirurgie,  Lief.  65,  p.  30. 

*  Walker  :  Quoted  by  Cooper,  loc.  cit.,  p.  80. 

*  Cooper  :   Loc.  cit.,  p.  76. 

®  Macouchy  :  Dublin  Hospital  Gazette,  1872,  vol.  i.  p.  21. 

^  Moxou  :   Medical  Times  and  Gazette.  1872,  vol.  i.  p.  96. 

»  Centralblatt  fur  Chirurgie,  1880,  p.  .504. 

9  Taylor  :   Lancet,  1881,  vol.  i.  p.  7:52. 

1"  Woodward  :  Boston  Medical  and  Surgical  Journal,  1883,  vol.  cviii.  p.  129. 
11  Perkins  :  Ibid.,  October  16,  1890,  p.  .362. 
>2  Cheever  :  Ibid.,  May  28,  1891,  p.  523. 


g-[2  I^ISL  OCA  TIOM. 

upon  the  groin"  and  through  the  skin.  Reduction;  suppuration; 
death  in  three  weeks.  The  second  is  not  spoken  of  by  Cooper  as  a 
compound  dislocation,  but  the  history  indicates  that  it  probably  was 
one ;  the  patient,  a  lad  seventeen  years  old,  was  run  over  by  a  wagon, 
the  wheel  passing  across  the  back  of  his  thigh  and  producing  a  dislo- 
cation forward  and  inward,  the  head  of  the  femur  lying  to  the  inner  side 
of  the  great  vessels.  A  rather  large  lacerated  wound  was  situated  just 
below  Poupart's  ligament,  a  little  to  the  inner  side  of  its  centre.  Pro- 
fuse suppuration  followed,  and  the  patient  died  on  the  twentieth  day. 

Macouchy's  patient  was  a  boy  fourteen  years  old,  who  fell  from  a 
mast  to  the  deck,  a  distance  of  sixty  feet,  and  received,  in  addition  to 
the  dislocation,  a  fracture  of  the  base  of  the  skull.  When  seen,  he 
was  sitting  on  the  deck  with  the  head  of  the  femur  appearing  between 
his  legs,  through  his  pilot-cloth  trousers,  as  if  protruded  from  his  anus. 
The  head,  neck,  and  great  trochanter  protruded  through  the  integu- 
ments covering  the  posterior  third  of  the  ischium,  the  head  of  the  bone 
resting  on  the  posterior  part  of  the  tuberosity  of  the  ischium  of  the 
opposite  side.  The  head  was  sawn  off,  and  the  shaft  replaced.  The 
patient  died  two  days  later. 

Moxon's  patient  was  injured  by  a  moving  train  and  died  shortly  after- 
ward in  Guy's  Hospital.  The  position  of  the  limb  was  that  of  disloca- 
tion on  the  dorsum  ilii.  There  was  a  large  irregular  rent  in  the  skin 
corresponding  to  the  junction  of  the  left  sacro-sciatic  ligament  with  the 
tuber  ischii.  On  passing  three  or  four  fingers  into  the  hole  a  way  was 
found  through  a  pulp  of  torn  muscles  and  bloodclot,  till  the  fingers 
rested  on  the  naked  head  of  the  thigh  bone.  The  gluteal  muscles  were 
much  torn  up  and  infiltrated  with  blood.  The  head  of  the  thigh  bone 
lay  half  an  inch  outside  the  great  sciatic  nerve,  free  under  the  remains 
of  the  glutei.  It  had  escaped  through  the  muscles  immediately  around 
the  joint  by  passing  between  the  quadratus  femoris  and  obturator 
internus.  A  portion  of  the  head  of  the  bone  remained  in  the  socket, 
attached  by  the  round  ligament. 

The  fifth  case  was  that  of  an  artilleryman  who  fell  in  front  of  the 
gun  ;  his  left  leg  was  bent  back  so  that  the  heel  lay  against  the  back 
of  the  shoulder,  and  the  head  of  the  femur  projected  through  the  fold 
of  the  groin.  There  was  profuse  bleeding  from  the  femoral  vein. 
Death  in  twenty-four  hours. 

Taylor's  patient  was  a  lad  seventeen  years  old,  who  was  overthrown 
by  a  falling  tree  and  received  a  dislocation  into  the  obturator  foramen 
together  with  an  irregular  wound  nearly  two  inches  long  in  the 
])erineum  through  which  the  head  of  the  femur  could  be  distinctly 
felt.  Most  of  the  muscles  had  been  separated  from  the  descending 
ramus  of  the  pubis  and  the  ascending  ramus  of  the  ischium.  Reduc- 
tion was  made  with  some  difficulty,  and  the  limb  immobilized  on  a  long 
side  splint.  The  wound  healed  promptly,  and  at  the  end  of  nine  weeks 
the  splint  was  removed,  but  on  the  next  day  inflammatory  symptoms  ap- 
peared on  the  side  of  the  hip,  and  an  abscess  formed  and  was  opened. 
Eight  months  later  Taylor  met  the  patient  riding  on  horseback. 

Woodward's  patient,  a  boy  twelve  years  old,  was  caught  under  a 
freight  car  and  rolled  over   and    over,  receiving  several  fractures  in 


MSLOCATIONS  OF  THE  HIP.  8l3 

addition  to  the  dislocation.  The  wound  was  a  slit  about  two  inches 
long  on  the  inner  side  of  the  thigh  two  and  a  half  inches  below  the 
angle  of  the  pubes.  The  head  of  the  femur,  together  with  the  great 
trochanter  entirely  stripped  of  its  muscles,  projected  completely  through 
the  opening  for  about  four  inches  and  lay  across  the  scrotun).  Its  point 
of  exit  was  just  anterior  to  the  adductor  longus.  No  fracture  of  the 
femur  or  pelvis  was  detected,  and  the  great  vessels  were  uninjured. 
The  patient  died  in  five  hours,  and  after  death  reduction  could  not  be 
made. 

Langmaid's  patient  was  a  girl  eight  years  old  who  had  been  run 
over  by  a  heavy  wagon.  The  w^ound  extended  from  a  point  one  inch 
above  and  within  the  anterior  superior  spine  across  the  groin  to  the 
inner  side  of  the  thigh,  the  head  of  the  femur  presenting  in  it  near  its 
centre.  "The  muscles  directly  under  the  wound  were  severed,  the 
adductor  longus  completely,  the  pectineus,  psoas,  and  gracilis  partially." 
Considerable  hemorrhage ;  the  femoral  vessels  were  "  outside  and 
beneath  the  neck  of  the  femur."  Reduction.  The  wound  suppu- 
rated, but  the  child  recovered  with  complete  anchylosis. 

Cheever's  patient,  a  man  fifty  years  old,  was  thrown  down  by  the 
fall  of  a  heavy  case  ;  the  head  of  the  femur  protruded  through  a  wound 
in  the  groin  below  the  outer  part  of  Poupart's  ligament.  The  head 
was  excised  ;  patient  died  on  the  third  day.  The  autopsy  showed  the 
femoral  vessels  to  be  intact.  Death  was  apparently  due  to  associated 
injuries,  shock,  and  extensive  fat  embolism  of  the  lungs. 

The  gravity  of  the  condition,  7  deaths  in  9  cases,  is  largely  due  to 
associated  injuries  and  shock,  5  deaths  ;  in  the  remaining  4  the  wound 
suppurated  after  reduction,  and  2  of  them  died.  The  urgent  question 
is  wliether  or  not  to  excise  the  head  of  the  femur  in  order  to  diminish 
the  danger  if  suppuration  should  follow.  In  fresh,  uninfected  cases 
I  should  think  it  unnecessary  if  ample  drainage  was  provided. 

Classification. 

The  classifications  adopted  by  the  earlier  writers  were  necessarily 
faulty  and  deficient  because  of  the  lack  of  recorded  experience  and 
post-mortem  examinations.  That  of  Hippocrates,  containing  four 
principal  forms,  outward,  inward,  forward,  and  backward,  was  em- 
ployed, according  to  Malgaigne,  until  the  seventeenth  or  eighteenth 
century,  although  the  terms  do  not  seem  always  to  have  been  api)]ied 
in  the  same  sense.  Petit,  in  the  eighteenth  century,  made  two  main 
groups,  inward  and  outward,  each  with  two  subdivisions,  the  four 
being  upward  and  inward,  downward  and  inward,  upward  and  out- 
ward, and  downward  and  outward,  but  he  thought  it  impossible  that 
the  latter  form  could  occur.  Verduc,  about  the  same  time  or  a  little 
earlier,  sought  to  establish  a  classification  based  upon  the  place  at  which 
the  head  of  tlie  femur  came  to  rest,  and  in  this  he  was  supported  by 
Duverney  and  Bertrandi,  and  thus  arose  the  terms  dislocation  upon  the 
ilium,  upon  the  ischiuia,  upon  the  pubes,  into  tlie  foramen  ovale.  Sir 
Astley  Cooper  gave  us  dislocations  upicard,  or  on  the  dorsum  ilii,  doum- 
ward,  or  into  the  foramen  ovale,  badcirard,  or  Into  tlie  ischlatlc  notch,  and 


814  DISLOCATIOM. 

dislocation  on  the  pubes ;  and  Gerdy  followed  with  sujjrapubic,  sub- 
pubic, iliac,  sacro-sciatic,  and  ischiatic,  the  latter  being  directly  down- 
ward. 

Malgaigne  was  the  first  to  bring  to  the  subject  the  results  of  careful 
study  of  many  pathological  specimens  ;  he  showed  that  in  the  back- 
ward dislocations  the  head  of  the  femur  did  not  go  so  far  as  the  ana- 
tomical terms  used  in  Cooper's  classification,  for  example,  w^ould 
indicate,  but  that,  on  the  contrary,  it  usually  remained  so  near  the 
cotyloid  cavity  that  it  partly  overlapped  it,  "incomplete"  disloca- 
tions, as  he  called  them,  and  he  proposed  a  classification  in  four  groups, 
of  which  the  first  two  were  the  same  as  Petit's,  though  the  names  are 
different,  as  follows : 

T\-  1      i-        V,    1        J         f    iliac,  complete,  incomplete. 
Dislocations  backward         {     •    ■<•  ^-  i  .      •  i  ^ 

I.    ischiatic,  complete,  incomplete. 

Dislocations  forward  <     •    i  ■         {■ 

I    ischio-pubic. 

Dislocations  upward  supracotyloid. 

„.,,.,  J         (    subcotyloid. 

Dislocations  downward        <        u       •       i 

t    subperineal. 

The  names  ilio-pubic  and  ischio-pubic  were  taken  from  those  of  cor- 
responding depressions  on  the  margin  of  the  cotyloid  cavity  along 
which  the  head  of  the  femur  was  thought  to  pass,  and,  acting  on  the 
same  plan,  Nelaton  gave  the  name  ilio-ischiatic  to  all  the  backward 
dislocations,  which  Malgaigne  preferred  to  divide  into  two  groups. 

In  Germany  Roser  and  Busch  adhered  to  the  method  of  classifica- 
tion according  to  the  direction  taken  by  the  head  of  the  femur ;  later, 
Albert  made  three  groups  :  bachvard,  fonvard  and  upward,  and  for- 
ward and  douinward,  and  K5nig  and  Lossen  four  :  backivard  (iliac  and 
ischiatic),  fonvard  {suprapubic  and  infrapubic),  supracotyloid,  in/ra- 
cotyloid. 

In  England  Sir  Astley  Cooper's  classification  has  been  quite  closely  ad- 
hered to,  although  some  surgeons  (Erichsen)  place  the  backward  dislo- 
cations, those  "  upon  the  dorsum  ilii  "  and  "  into  the  sciatic  notch," 
in  one  group  and  call  them  "  dislocations  backward  and  upward." 

In  America  Hamilton  used  Cooper's  classification  ;  and  Agnew  did 
the  same,  although  he  grouped  the  iliac  and  ischiatic  together  as  vari- 
eties of  a  single  form  "  upward  and  backward." 

Bigelow,^  to  whose  researches  and  writings  so  much  of  the  later 
advance  in  the  knowledge  of  the  subject  and  in  the  treatment  of  the 
injury  is  due,  made  a  classification  of  seven  regular  and  principal 
forms,  which  he  based  not  merely  upon  the  direction  in  which  the  bone 
had  been  dislocated  or  the  point  at  which  it  came  to  rest,  but  also  upon 
the  integrity  of  the  Y-ligament  or  the  rupture  of  its  outer  branch,  and 
the  changes  in  the  attitude  of  the  limb  which  arise  from  such  rupture. 
Such  a  classification  was  open  to  the  objection  that  it  gave  equal  rank 
to  forms  which  were  only  variations  of  others,  and  a  few  years  later  he 
modified  it^  by  grouping  all  under  four  heads  and  by  suppressing  the 
distinction  between  the  "  dorsal "  and  the  "  dorsal  below  the  tendon," 

'  Bigelow:  The  Hip.  2  Bigelow:  Lancet,  1878,  vol.  i.  p.  894. 


DISLOCATIONS  OP  THE  HlP.  gl5 

which  latter  name  he  had  previously  given  to  the  lower  of  the  two 
dorsal  varieties,  the  "  dislocations  into  the  sciatic  notch"  of  Cooper. 
His  new  classification,  then,  was  the  following : 

External  to  the  socket;  comprising  the  dorsal  and  the  dorsal  with 
eversion. 

Internal  to  the  socket ;  on  the  perineum,  the  thyroid  foramen,  and 
the  pubes. 

Below  the  socket ;  dislocation  toward  the  tuberosity  of  the  ischium. 

Above  the  socket ;  the  subspinous,  the  supraspinous,  and  the  anterior 
oblique. 

This  also  was  open  to  the  serious  objection  that  varieties  which  were 
alike  in  their  mode  of  production,  in  the  point  at  which  the  head  of 
the  femur  left  the  socket,  in  the  direction  it  afterward  took,  and  in 
treatment  were  placed  in  different  main  divisions,  and  he,  therefore, 
went  further  and  presented  in  the  same  paper  the  following  classifica- 
tion which  he  recommended  as  a  sufficient  "  practical  grouping." 

Dorsal,  comprising  the  dislocation  on  the  tuberosity  of  the  ischium,  the 
dorsal,  the  everted  dorsal,  the  anterior  oblique,  and  the  supraspinous. 

Thyroid,  comprising  that  in  the  perineum  and  that  on  the  thyroid 
foramen. 

Pubic,  comprising  the  pubic  and  the  subspinous. 

Turning  now  to  the  results  of  the  examination  of  specimens  and  of 
experiments  upon  the  cadaver,  it  appears  that  in  the  more  frequent 
forms  the  head  of  the  femur  passes  over  the  outer,  posterior,  margin 
of  the  cotyloid  cavity,  usually  at  or  below  its  horizontal  diameter, 
while  the  limb  is  flexed,  adducted,  and  rotated  inward ;  then  by 
the  sinking  of  the  knee  the  femur  turns  upon  its  attachment  to  the 
Y-ligament  as  a  centre,  and  the  head  rises  to  a  higher  level  along  the 
outer  surface  of  the  acetabulum  or  further  backward  on  the  flat  surface 
of  the  ilium  in  front  of,  and  seldom  higher  than  the  apex  of,  the  great 
sciatic  notch.  It  is  to  be  borne  in  mind  that  this  apex  is  not  very 
much  above  the  level  of  the  highest  part  of  the  cotyloid  margin.  In 
this  movement  the  head  of  the  femur  may  pass  behind  the  untorn  ten- 
don of  the  obturator  internus,  leaving  that  tendon  between  itself  and 
the  acetabulum  ;  or,  if  it  crosses  the  margin  of  the  cotyloid  cavity  at  or 
above  its  horizontal  diameter,  it  may  tear  the  obturator  internus  and 
pyriformis  or  pass  between  these  muscles  and  come  to  rest  at  the  same 
point  as  before.  The  former  is  the  dislocation  "  below  the  tendon," 
the  latter  the  "  dorsal "  or  the  dislocation  "  upon  the  dorsum  ilii,"  as 
tliese  terms  were  originally  used,  but  the  distinction  is  one  which  can- 
not often  be  made  clinically.  The  important  diiference  between  them 
is  in  the  situation  of  the  rent  in  the  capsule,  which  is  higher  in  the 
latter  than  in  the  former,  and  will  probably  permit  reduction  by  trac- 
tion obliquely  downward. 

Exceptionally,  if,  after  the  dislocation  has  occurred,  the  knee  is  still 
further  lowered  and  the  limb  abducted  and  rotated  outward,  the  outer 
branch  of  the  Y-ligament  ruptures  and  the  head  of  the  femur  passes 
forward  along  the  ilium  toward  its  anterior  inferior  spine  or  the 
interval  between  the  two  spines,  the  '^  everted  dorsal  "  of  Bigelow, 
the  "  supraspinous  "  or  part  of  the  "  supracotyloid  "  of  others.     The 


816  DiSLOOATtONS. 

attitude  of  the  limb  in  this  is  very  diiferent  from  that  of  the  com- 
mon backward  dislocation  of  which  this  is  a  variety  by  secondary 
displacement. 

But  the  head  of  the  femur  may  not  only  come  to  rest  directly  above 
the  cotyloid  cavity  by  a  secondary  displacement  forward  and  inward  ; 
it  may  also  reach  nearly  the  same  point  by  a  secondary  displacement 
outward  and  backward  from  a  primary  dislocation  forward  upon  the 
pubis.  The  distinction  between  the  two  is  radical,  for  in  the  former 
the  root  of  the  Y-ligament  lies  on  the  inner  side  of  the  head,  which 
must  be  returned  to  its  socket  by  passing  backward  behind  the  ace- 
tabulum ;  and  in  the  latter  the  Y-ligament  lies  to  its  outer  side  and 
the  head  must  be  returned  along  the  front  or  inner  side  of  the  acetab- 
ulum. There  is  still  a  third  way  in  which  the  head  may  be  placed 
above  the  acetabulum,  although  at  a  somewhat  lower  level,  and  that  is 
by  direct  displacement  upward,  with  rupture  of  the  upper  part  of  the 
capsule  and  of  the  Y-ligament,  but  this  is  extremely  rare. 

The  dislocations  forward  (or  inward)  and  upward  and  inw^ard  and 
downward  offer  no  difficulties  in  classification ;  each  has  its  character- 
istic symptoms,  although  the  perineal  variety  of  the  latter  is  somewhat 
sharply  distinguished  from  the  obturator  or  thyroid  variety  by  the 
greater  flexion  and  abduction  of  the  limb.  Bigelow  thinks  the  supra- 
pubic can  be  produced  by  a  secondary  displacement  upward  after  the 
head  has  escaped  at  the  lower  part  of  the  capsule  during  flexion  of  the 
limb,  in  a  similar  manner  and  by  the  same  mechanism  (lowering  of  the 
knee)  as  a  secondary  "iliac"  dislocation  is  produced  from  a  primary 
"  ischiatic"  one.  In  short,  he  thinks  {Lancet,  1878)  that  in  most  cases 
the  head  of  the  femur  escapes  over  the  lower  margin  of  the  acetabulum 
and  then  passes  upward  as  the  limb  is  lowered,  and  either  behind  or 
in  front  of  the  acetabulum  according  as  the  limb  is  adducted  or 
abducted,  and  upon  this  theory  he  bases  a  simple  rule  of  treatment 
applicable  to  both  anterior  and  posterior  dislocations,  namely,  flex  the 
limb  at  a  right  angle  to  bring  the  head  below  the  socket,  and  then  lift 
it  into  place. 

Finally,  the  head  may  be  displaced  downward  upon  the  adjoining 
branch  of  the  ischium,  and  rest  there  (subcotyloid) ;  the  position  is  one 
from  which  the  head  can  be  easily  displaced  backward  or  forward,  and 
the  dislocation  thereby  transformed  into  a  dorsal  or  obturator. 

The  distinction  between  the  two  backward  forms,  upon  the  dorsum 
ilii  and  toward  the  sciatic  notch,  which  has  already  been  abandoned  by 
eminent  surgeons  (Bigelow,  Erichsen,  Albert),  does  not  appear  to  de- 
serve to  be  retained,  except,  perhaps,  to  establish  corresponding  vari- 
eties in  the  group;  and  the  anterior  oblique,  everted  dorsal,  and  supra- 
spinous clearly  belong  in  the  same  class  by  their  mode  of  production 
and  treatment.  The  class  of  supracotyloid  dislocations,  made  by  some 
writers  to  contain  the  two  last  mentioned,  the  rare  dislocations  directly 
upward,  and  some  of  the  suprapubic,  will  be  limited  to  those  in  which 
the  head  appears  to  have  moved  directly  upward.  The  corresponding 
class  and  term  of  "  subcotyloid  "  must  be  retained  for  the  rare  dislo- 
cations downward  "  upon  the  tuberosity  of  the  ischium." 


BACKWARD  DISLOCATIONS  OF  THE  HIP.  8l7 

The  terms  upward  and  downward  must  not  be  taken  too  literally. 
They  appear  to  have  been  rather  carelessly  used  at  first  without  strict 
regard  to  the  normal  position  of  the  pelvis.  When  the  body  is  upright, 
the  upper  border  of  the  symphysis  pubis  lies  a  little  below  the  level 
of  the  centre  of  the  cotyloid  cavity,  and  the  tuberosity  of  the  ischium 
lies  not  directly  below  this  cavity,  but  below  and  behind.  The  classi- 
fication, then,  whicli  will  here  be  used  is  as  follows  : 

f  doisal,  comprising  the  "  iliac"  and  "  ischiatic,"  or 

I  those  "  upon   the   dorsum   ilii "  and  "  into  tlie 

T^,.  ,       ,.       1      ,          ]         I  ischiatic  notch"  of  the  writers. 

Dislocation  backward         -|  ^^^^.^^^  ^^^.^^1^   comprising  the   anterior  oblique, 

I        "supraspinous,"  and  some  of  the   "supracoty- 
[      loid." 
Dislocations  downward      (  obturator, 
and  inward  I.  perineal. 

-r^.  ,       ,.        J.  J  ,  f  ilio-pectineal. 

Dislocations  forward  \  ,^,i^  bic. 

and  upward  )      ^     ^  1  intrapelvic. 

Dislocations  directly  upward  (supracotyloid  or  subspinous). 
Dislocations  downward  on  the  tuberosity  of  the  ischium. 

As  in  the  classification  of  dislocations  of  the  shoulder,  the  names  of 
the  principal  groups  indicate  the  direction  of  the  primary  displacement 
and,  consequently,  the  position  of  the  rent  in  the  capsule,  and  the 
names  of  the  varieties  show  either  the  place  at  which  the  head  of  the 
femur  comes  to  rest  or  the  special  symptomatic  feature  which  marks 
the  variety. 

BACKWARD  DISLOCATIONS. 

1.  Dorsal. 

2.  Everted  dorsal. 

In  this  class  of  dislocations  the  head  of  the  femur  in  leaving  the 
cotyloid  cavity  passes  over  its  posterior  margin  at  a  higher  or  lower 
point  while  the  limb  is  flexed,  adducted,  and  rotated  inward.  In  the 
great  majority  of  cases  the  limb  preserves  this  attitude,  and  the  head 
rests  not  far  from  and  behind,  or  behind  and  above,  the  margin  of  the 
acetabulum,  between  it  and  the  great  sciatic  notch,  or  it  may  lie  a 
little  higher  upon  the  concave  surface  of  the  ilium  ;  these  constitute 
the  dorsal  variety,  and  include  the  ''  iliac  "  and  "  ischiatic  "  of  other 
writers.  In  other  cases  external  rotation  of  the  limb  takes  place  with 
or  without  abduction  and  extension  ;  in  the  latter  case  the  limb  crosses 
the  opposite  thigh  and  the  toes  are  everted,  tiie  head  of  the  femur  lies 
above  the  socket,  and  the  lower  part  of  the  neck  corresjionds  to  the 
upper  and  posterior  margin  of  the  acetabulum,  the  anterior  oblique 
variety ;  in  the  former  case  (with  abduction  and  extension)  the  outer 
branch  of  the  Y-ligament  is  ruptured,  the  head  of  the  femur  lies 
above  the  socket,  and  the  everted  limb  lies  ])arallel  to  its  fellow,  or 
slightly  abducted — the  everted  dorsal  variety.  The  class  includes  all 
the  backward  dislocations  of  other  authors,  and  most  of  those  that 
have  sometimes  been  grouped  under  the  term  "  supracotyloid." 


gig  DtSLOGATlONS. 

1,  Dorsal  Dislocations. 

In  these  dislocations,  which  are  by  far  the  most  common  of  all  dis- 
locations of  the  hip,  the  head  of  the  femur  lies  behind  and  above  the 
cotyloid  cavity,  either  close  to  and  overlapping  its  edge  (Malgaigne's 
"  incomplete "  form)  or  further  away  upon  the  ilium.  It  may  pass 
below  the  obturator  intern  us  and  rise  behind  it,  or  between  it  and  the 
pyriformis,  or  above  the  latter,  or  both  muscles  may  be  completely 
torn  across.  The  group,  therefore,  includes  the  dislocations  "  upon 
tlie  dorsum  ilii"  and  those  "into  the  ischiatic  notch"  of  Cooper,  or 
the  "  dorsal "  and  the  "  dorsal  below  the  tendon  "  of  Bigelow's  first 
classification,  or  the  "iliac"  and  "ischiatic"  of  others. 

Causes.  Dorsal  dislocations  are  commonly  caused  by  violence  that 
approximates  the  knee  and  the  pelvis  while  the  thigh  is  flexed, 
adducted,  and  rotated  inward,  as  in  a  fall  from  a  height,  or  in  the  fall 
of  a  heavy  body  upon  the  back  of  the  patient  while  he  is  stooping  for- 
ward. Less  frequently  the  dislocation  is  produced  mainly  or  solely 
by  flexion,  adduction,  and  inward  rotation,  one  of  the  three  move- 
ments being  exaggerated.  Thus,  in  a  case  reported  by  Moffat,^  the 
patient  was  drawing  a  railway  carriage  along  the  track ;  he  fell  for- 
ward and  rolled  upon  his  back  outside  the  rail  to  escape  the  car,  but, 
as  it  passed,  the  end  of  the  footboard  caught  his  leg  and  bent  it  upon 
and  across  his  belly  (flexion  and  adduction).  The  car  had  to  be  raised 
with  a  jack-screw  to  free  him,  and  when  released  he  was  lying  upon 
his  back  with  the  limb  in  the  position  described.  When  examined  at 
the  hospital,  the  thigh  was  slightly  flexed  and  rotated  inward,  the  toes 
overlapping  those  of  the  other  foot. 

In  a  case  reported  by  Dupuytren,  exaggerated  adduction  appears  to 
have  been  the  chief  factor.  A  delicate  man,  twenty-one  years  old, 
was  thrown,  while  wrestling,  upon  his  left  side,  and  in  the  fall  the  left 
thigh  was  forcibly  carried  across  the  front  of  the  other  by  contact  of 
the  side  of  the  knee  with  the  ground.  In  a  case  observed  by  Mal- 
gaigne,  and  in  another  quoted  by  him  from  Mercier,  exaggerated 
inward  rotation  appeared  to  be  the  principal  cause;  both  patients  were 
women  who  slipped  and  twisted  the  foot  inward  while  walking. 

A  case,  exceptional  not  only  by  its  mode  of  production  but  also  by 
the  age  of  the  patient,  was  reported  by  Bartels  and  has  been  referred 
to  above.  The  patient  was  a  child  eleven  months  old,  and  the  dislo- 
cation was  caused  by  the  effort  of  a  shoemaker  to  put  on  its  shoe  while 
it  was  sitting  on  its  nurse's  knee. 

In  two  cases  in  which  the  head  was  split  into  two  pieces,  one  of 
which  remained  in  the  socket  attached  to  the  ligamentum  teres,  it  is 
evident  that  the  flexion,  adduction,  and  rotation  were  not  carried  far 
enough  to  turn  the  head  out  of  the  socket,  and  the  dislocation,  strictly 
speaking,  was  a  complication  of  a  fracture  of  the  head  produced  by 
violent  pressure  of  the  inner  segment  against  the  outer  and  upper 
margin  of  the  cavity;  in  like  manner  the  dislocation  maybe  facili- 
tated by  the  breaking  off  of  a  considerable  portion  of  the  acetabular 
ring.     There  is  reason  to  think  that  some  dislocations  are  produced  in 

1  Moffat :  Lancet,  1878,  vol.  ii.  p.  251. 


BACKWARD  DISLOCATIONS  OF  THE  HIP.  819 

this  manner  by  violence  acting  directly  upon  the  upper  part  of  the 
thigh,  as  in  the  passage  across  it  of  the  wheel  of  a  heavy  wagon. 

It  is  by  no  means  uncommon  for  a  dorsal  dislocation  to  be  produced 
by  the  transformation  of  one  downward  and  inward  (obturator)  during 
manipulations  made  to  effect  reduction,  the  head  passing  below  and  be- 
hind the  acetabulum  during  flexion  and  adduction  of  the  limb,  and,  in 
like  manner,  a  dorsal  may  be  transformed  into  an  obturator  dislocation. 

Occasionally  dorsal  dislocation  takes  place  gradually  while  the 
patient  is  confined  to  bed  by  illness,  especially  by  acute  articular  rheu- 
matism and  the  infectious  or  eruptive  fevers.  These  "  spontaneous  " 
dislocations  are  considered  in  Chapter  LIU. 

Pathology.  The  condition  of  the  capsule  and  of  the  muscles  about 
the  joint  and  the  position  of  the  head  of  the  femur  have  been  clearly 
shown  by  direct  examination  of  a  considerable  number  of  specimens 
of  recent  dislocation,  and  by  old  ones,  and  by  experiment  upon  the 
cadaver.  Among  the  autopsies  of  fresh  dislocations  recently  reported 
may  be  mentioned  those  by  Moxon,^  MacCormac,^  Adams,^  Morris,* 
Lee,^  Humphry^  three  cases,  Rutherford,^  Stimson,^  and  Walker'*;  of 
older  cases  examined  during  reduction  by  arthrotomy  the  largest  per- 
sonal experience  is  Dollinger's,^"  12  cases. 

The  capsule  is  torn  always  in  its  lower  posterior  part,  and  usually 
also  in  its  under  part,  but  the  rent  varies  greatly  in  extent  and  sliape. 
Frequently  it  lies  about  midway  between  the  upper  and  lower  posterior 
insertions  of  the  capsule;  sometimes  the  capsule  is  torn  away  from  the 
femur,  and,  rarely,  away  from  the  acetabulum. 

In  Morris's,  Lee's,  and  Walker's  cases  the  conditions  were  exceptional ; 
in  the  former  (Fig.  448)  "  the  capsule  was  ruptured  on  its  lower  and 
inner  side,  and  w^as  clearly  peeled  up  from  off  the  back  of  the  neck  of 
tlie  femur  as  far  as  the  digital  fossa.    The  rent 
c:>mmenced  below  the  pectineo-femoral  band,  Fig.  448. 

midway  between  the  acetabulum  and  the  femur 
and  ran  (1)  out.vard  and  backward  to  the  neck 
of  the  latter,  which  it  reached  just  above  and 
behind  the  small  trochanter,  and  (2)  inward 
and  backward  across  the  thin  portion  of  the 
capsule  toward  the  acetabulum,  which  it  nearly 
reached  a  little  behind  the  ischial  border  of  the 
cotyloid  notch.  It  thus  formed  two  sides  of 
a  large  opening  which  was  made  quadrilateral  Morris's  case  of  dorsal  disio- 
in  form  by  the  detachment  of  the  flap  from  the     '^'^^i"":  f°'"^i'"  "e-^ed  and  ab- 

11         i"    ii        i?  1  1    J5        T7'    •  ]      ii       ii  ducted  to  show  the  rent  in  the 

back    or    tlie   temoral  neck.         Lvidently  the     capsule. 
head  had  escaped  downward. 

1  Moxon  :  Medical  Times  and  Gazette.  1872,  vol.  i.  p.  96. 

2  MacCorniac:  St.  Thomas's  Hospital  Reports,  1871,  vol.  ii.  p.  143. 

*  Adams:  Transactions  of  the  PatlioloKical  Society  of  London,  1870,  vol.  xxi.  p.  305. 

*  Morris:  Medico-ChirnrKical  Transactions,  1877,  vol.  Ix.  p.  KJl. 

*  Lee:  St.  George's  Hospital  Reports,  1872-74,  vol.  vii.  p.  lfJ9. 

*  Humphry:  Lancet,  188(),  vol.  ii.  p.  1011. 

■f  Rutherford  :  Glasgow  Medical  .fournal.  May,  1889. 

8  Stimson  :   New  York  Medical  .Journal,  August  10,  1889,  p.  163. 

9  Walker:   Detroit  Lancet,  .Inly,  1879. 

10  Dollinger:  Ergebnisse  der  (hir.  und  Orthop.,  1911,  vol.  iii. 


820  DISLOCATIONS. 

In  Lee's  case  the  capsule  was  "  freely  lacerated  all  around,  a  small 
portion  remaining  attached  to  the  femur  in  front  and  behind."  This 
was,  therefore,  an  "  irregular  "  dislocation,  and  to  the  extensive  lacera- 
tion of  the  capsule  corresponded  a  variation  in  the  symptoms  which 
fully  corroborates  Bigelow's  views ;  the  report  says :  ''  Two  of  the 
main  signs  of  dislocation  were  absent,  namely,  the  advanced  position 
of  the  knee  with  the  foot  resting  upon  the  opposite  one,  and  marked 
shortening."  The  head  of  the  femur  was  below  the  pyriformis  muscle 
and  immediately  behind  the  acetabulum. 

In  Walker's  the  posterior  rim  of  the  acetabulum  had  been  broken  off, 
the  posterior  half  of  the  capsule  torn  away,  and  the  bone  displaced  to 
an  unusual  distance.     The  violence  had  been  very  great. 

The  preservation  of  the  anterior  portion  of  the  capsule,  the  ilio- 
femoral ligament,  is  constant,  as  has  been  said,  in  the  cases  which 
Bigelow  terms  "  regular,"  those  which  are  marked  by  the  common 
and  characteristic  symptoms  of  the  dislocation,  and,  as  he  also  pointed 
out,  the  strong  portion  of  the  capsule  at  its  upper  and  posterior  part  is 
also  usually  untorn  and  opposes  the  ascent  of  the  head  upon  the  ilium. 
The  ligamentum  teres  is  usually  torn  from  its  attachment  to  the 
femur,  but  sometimes  is  ruptured. 

Of  the  muscles,  the  quadratus  femoris  is  usually  completely  torn 
across,  but  sometimes  (Humphry,  Dollinger)  is  intact ;  the  gemelli 
commonly  are  torn,  but  the  obturator  internus  which  is  so  closely  asso- 
ciated with  them  frequently  escapes  or  is  only  partly  lacerated,  prob- 
ably because  of  its  greater  length.  The  pyriformis  and  obturator 
extern  us  are  sometimes  torn  partly  or  entirely  across ;  the  glutei 
usually  escape  injury  entirely  or  are  only  slightly  lacerated. 

The  head  of  the  femur  may  lie  close  to  the  margin  of  the  acetabu- 
lum, even  overlapping  the  cavit}^,  or  it  may  be  displaced  to  a  variable 

distance  backward  or  backward  and  up- 
Fig.  449.  ward.     The  lowest  point  at  which  its 

centre   rests  is  the  base    of  the    spine 
Pyrifoum'i^^^^'  ^"^^^  of  the  ischium  (Adams  ^  and  Quain^) 

overlapping  both  sciatic  notches ;  and 
the  highest,  except  perhaps  in  excep- 
tional cases,  appears  to  be  opposite  the 
apex  of  the  great  sciatic  notch,  which, 
in  the  recumbent  position,  is  directly 
below  the  anterior  superior  spine  of  the 
mw^   m,  y  m  ilium,  the  line  uniting  the  two  passing 

about  an  inch  above  the  margin  of  the 
cotvloid  cavity.    Fifty  years  ago  Quain 

Dislocation  below  and  then  behind  and        i'  j.j.]i,  j.  ia 

above  the  obturator  internus.  <lemonstrated    by    autopsy^   the    error 

contained  in  the  name  given  by  Sir 
Astley  Cooper  to  the  lower  form  of  dislocation  "  into  the  sciatic  notch," 
and  formally  called  attention  to  it ;  and  a  few  years  later  Malgaigne 
showed  that  the  head  of  the  bone  was  much  less  upon  the  ilium  in  the 
higher  form  than  was  supposed,  and  further  that  in  many,  perhaps  a 

1  Adams  :  Loo.  cit. 

2  Quain  :  Medico-Chirurgical  Transactions,  1848,  vol.  xxxi.  p.  337. 


BACKWARD  DISLOCATIONS  OF  THE  HIP. 


821 


majority,  of  the  dislocations  "  upon  the  dorsum  ilii "  the  femur  left  the 
socket  at  its  lower  posterior  part  and  subsequently  passed  upward,  so 
that  in  such  cases  the  primary  dislocation  was  "ischiatic,"  and  the 
"iliac"  was  secondary.  This  view  has  l)een  amply  confirmed.  In  11 
specimens  of  old  dislocations  which  Malgaigne  examined,  the  head  of 
the  femur  rose  in  5  only  to  the  level  of  a  line  drawn  from  the  anterior 
superior  spine  of  the  ilium  to  the  apex  of  the  great  sciatic  notch,  in  2 
it  rose  half  a  centimetre  above  this  line,  in  2  one  centimetre,  in  1  one 
and  a  half  centimetres,  and  in  1  two  centimetres.  There  is  no  reason 
to  suppose  that  in  old  dislocations  the  head  is  at  a  lower  level  than  in 
recent  ones,  indeed  it  is  probably  somewhat  higher. 

When  the  head  of  the  femur  leaves  the  socket  at  its  lower  part  it 
passes  usually  below  the  obturator  internus  and  then  rises  behind  it, 
so  that  this  muscle  is  interposed  between  it  and  the  acetabulum  (Fig. 
449).  Or  it  may  lie  immediately  beneath  the  obturator  internus  and 
press  it  forcibly  upward,  as  in  Adams's  case  (Fig.  450),  which  remained 
unreduced  until  the  patient's  death  on  the  fourteenth  day,  and  in  which 
the  muscle  was  so  tightly  stretched  over  the  upper  part  of  the  head 
that  a  deep  groove  had  formed  in  the  articular  cartilage  of  the  latter 
exactly  corresponding  in  size  and  direction  to  the  tendon ;  the  head 
rested  on  the  spine  of  the  ischium,  and  the  obturator  externus  and 
quadratus  femoris  were  ruptured.  Or  the  head  may  pass  above  the 
obturator  internus,  between  it  and  the  pyriformis,  as  in  MacCormac's 
case  (Fig.  451),  in  which  it  rested  "  behind  the  acetabular  ridge  opposite 


Fig.  450. 


Fig. 451. 


Adams's  case  :  a,  head  of  femur ;  6,  obturator 
externus  ruptured  ;  c,  quadratus  femoris  rup- 
tured; d,  sciatic  nerve. 


MacCormac's  specimen  of  recent  dorsal  dis- 
location. The  head  of  the  femur  lies  just  be- 
hind the  acetabulum,  below  the  pyriformis, 
and  above  the  obturator  interniis  and  the  torn 
gemellus  muscles. 


the  middle  and  upper  j)art  of  the  great  ischiatic  foramen,  behind  the  pos- 
terior border  of  the  gluteus  medius,  and  only  covered  by  the  gluteus 
maximus  and  the  integument."  This  is  an  example  of  a  real  primary 
"iliac"  dislocation,  and  the  rent  in  the  capsule  was  "merely  on  the 


322  DISLO  CA  TIONS. 

back  part,  and  the  neck  was  as  it  were  locked  over  the  acetabular  ridge, 
and  the  strong  anterior  part  of  the  capsule  was  tightly  stretched." 

The  edge  of  the  acetabulum  is  sometimes  chipped,  and  in  two  of 
the  cases  above  quoted  (Quain,  Morris)  there  was  a  fracture  through 
the  ilium  into  the  cotyloid  cavity,  and  in  the  latter  there  was  also  a 
fracture  of  the  ramus  of  the  ischium.  In  both  cases  the  injury  was 
caused  by  great  violence. 

In  2  of  Dollinger's  cases  there  was  a  fracture  running  through  the 
acetabulum  from  the  ilium  or  pubis,  and  in  3  others  a  piece  of  the  rim 
of  the  acetabulum  of  considerable  size  was  broken  off;  one  of  them  lay 
in  the  cotyloid  cavity. 

In  all  but  one  of  his  old  (four  weeks  upward)  unreduced  cases 
Dollinger  found  the  cotyloid  cavity  filled  with  fibrous  tissue  and  fat, 
sometimes  enclosing  small  bits  of  bone.  The  cartilage  of  the  head  of 
the  femur  was  covered  in  3  cases  by  a  thin  loosely  attached  membrane; 
occasionally  it  was  discolored,  and  once  or  twice  it  was  chipped  or 
crushed. 

In  a  case  reported  by  Birkett^  the  head  of  the  femur  was  split  ver- 
tically, the  inner  half  remaining  in  the  acetabulum  and  still  attached 
to  the  ligamentum  teres,  and  the  other,  continuous  with  the  neck, 
being  displaced  backward  above  the  obturator  internus.  A  similar 
case,  quoted  above  among  compound  dislocations,  p.  812,  was  reported 
by  Moxon  ;  and  in  another  reported  by  Eiedel "  the  head  and  neck  were 
split  longitudinally,  both  fragments  being  displaced  from  the  socket. 
Crile^  reported  a  case  of  fracture  of  the  posterior  third  of  the  head 
and  of  the  posterior  half  of  the  rim  of  the  acetabulum.  In  my  case 
the  head  of  the  femur  was  deeply  indented,  apparently  by  contact  with 
an  osteophyte  close  behind  the  rim  of  the  acetabulum,  and  a  portion 
of  the  labrum  cartilagineum  had  been  broken  off.  In  a  case  seen  by 
Lossen  *  the  neck  of  the  femur  had  been  broken  at  the  moment  of  dis- 
location, but  doubtless  after  the  head  of  the  bone  had  left  the  socket. 
In  several  reported  cases  the  neck  has  been  broken  during  an  attempt 
to  reduce,  and  in  a  few  in  which  fracture  has  been  recognized  it  has 
remained  uncertain  whether  it  occurred  simultaneously  with  the  dislo- 
cation or  was  caused  by  the  surgeon.     (See  Chapter  LI II.) 

The  sciatic  nerve  commonly  lies  behind  the  head  of  the  femur  and 
at  the  most  is  only  slightly  pressed  upon,  but  in  Quain's  case  it  was 
stretched  over  the  neck  of  the  femur. 

Symptoms.  The  patient  is  unable  to  bear  his  weight  upon  or  volun- 
tarily to  move  his  injured  limb  ;  if  he  stands  upright  it  shows  moder- 
ate flexion  and  adduction,  marked  inversion,  and  more  or  less  shorten- 
ing, the  toes  resting  on  those  of  the  other  foot.  When  he  is  placed 
upon  his  back  the  apparent  adduction  and  flexion  are  increased,  the 
knee  resting  just  above  the  other  patella  or  crossing  the  thigh  at  a 
higher  point.  The  contours  of  the  outer  and  posterior  regions  of  the 
hip  are  changed  by  loss  of  the  normal  depression  behind  the  trochanter, 
elevation  of  the  gluteal  fold,  and  abnormal  fulness  due  to  the  approxi- 

'  Birkett  :  Medico-Chirurgical  Transactions,  1869,  vol.  lii.  p.  133. 

*  Riedel  :  Beilage  zum  Centralbl.  fiir  Chir.,  1885,  p.  92. 

'  Crile  :  Annals  of  Surgery,  May,  1891.  *  Lossen  :  Deutsche  Chir.,  Lief.  65,  p.  55. 


BACKWARD  DISLOCATIONS  OF  THE  HIP. 


823 


mation  of  the  insertions  of  the  gluteal  muscles.  The  trochanter  rises 
to  a  \'ariable  distance  above  the  line  drawn  from  the  anterior  superior 
spine  of  the  ilium  to  the  tuberosity  of  the  ischium,  and  its  distance 


Fig.  452. 


Dorsal  dislocation  of  the  hip. 

from  the  first-named  })rominenoe  is  increased.  The  liead  of  the  feninr 
can  be  obscurely  felt  throngh  tlie  glutens  maximus  and  recognized  by 
its  movements  when  the  limb  is  flexed  or  rotated.  The  empty  socket 
cannot  be  felt  from  in  front,  becansc  it  is  covered  by  the  anterior  por- 
tion of  the  capsule  and  the  psoas  and  iliacus,  but  the  depressil)ility 
of  the  soft  parts  in  Scarpa's  space  is  as  great  as,  or  greater  than,  that 
on  the  0])posite  side,  whereas  in  fracture  of  the  neck  of  the  femur  this 
depressibility  is  diminished. 
57 


824  DISLOCATIONS. 

The  limb  can  be  still  further  adducted  and  flexed,  but  it  cannot  be 
abducted  or  rotated  outward.  The  apparent  shortening  varies  greatly 
in  degree  in  different  cases,  and  the  actual  shortening  cannot  always  be 
determined  with  accuracy  because  of  the  difficulty  in  placing  the  limbs 
symmetrically.  Concerning  this  shortening  the  most  contradictory 
statements  have  been  made ;  some  surgeons,  relying  solely  upon  the 
appearance  of  the  limb  and  seeing  that  the  knee  lay  well  above  the 
opposite  one,  have  described  the  shortening  as  great ;  others,  looking 
only  to  the  new  relations  of  the  bones  as  shown  upon  the  skeleton, 
have  described  the  shortening  as  moderate  or  even  as  absent  in  the 
lower  forms.  The  error  in  the  first  arises  from  not  taking  into  account 
the  eifect  of  adduction  to  create  an  apparent  shortening  of  the  adducted 
limb  when  compared  with  its  non-adducted,  still  more  with  its  abducted, 
fellow ;  that  in  the  second  arises  from  considering  the  question  only 
with  reference  to  the  position  of  extension.  If  the  head  of  the  femur 
is  displaced  backward  toward  the  spine  of  the  ischium,  the  length  of 
the  limb  measured  in  extension  (if  that  is  possible)  from  the  anterior 
superior  spine  of  the  ilium  to  the  knee  or  ankle  will  not  be  diminished, 
for  the  movement  backward  of  the  head  has  been  at  right  angles  to  the 
line  of  measurement  and  has  not  brought  the  knee  any  nearer  to  the 
pelvis ;  but  if  the  measurement  is  made  while  the  thigh  is  flexed  at 
a  right  angle  the  measured  length  will  be  less  by  about  two  inches  than 
that  of  the  other  limb  in  the  same  position,  for  now  the  measured  line 
is  nearly  parallel  to  the  direction  of  displacement.  When  the  head  is 
displaced  upward  as  well  as  backward  the  difference  in  the  amount  of 
shortening  in  these  two  positions  of  the  limb  is  much  less,  for  the  direc- 
tion of  the  displacement  deviates  at  about  the  same  angle  from  the 
measured  line  in  each  attitude.  Of  course,  in  each  limb  the  measured 
length  is  less  when  the  thigh  is  flexed,  but  the  difference  in  the  com- 
parative measurements  of  the  two  limbs  is  not  affected  in  the  high  dis- 
locations and  is  greatly  affected  in  the  low  ones.  In  making  measure- 
ments the  two  limbs  must  be  symmetrically  placed  as  regards  flexion 
and  adduction,  and  the  fixed  adduction  of  the  injured  limb  sometimes 
interferes  seriously  with  the  accomplishment  of  this  condition,  for  its 
knee  occupies  the  position  to  which  the  other  one  should  be  brought, 
and,  therefore,  an  equal  adduction  cannot  be  given  to  the  sound  limb 
without  carrying  its  knee  across  at  a  higher  or  lower  level,  and  thus 
giving  it  an  unsymmetrical  flexion.  It  must  also  be  remembered  that 
apparent  symmetry  of  position  is  not  sufficient,  the  symmetry  must  be 
real  in  that  the  angles  of  flexion  and  adduction  on  the  pelvis  are  the 
same.  Fortunately  the  exact  determination  of  the  shortening  is  not 
necessary  to  the  diagnosis  of  the  dislocation. 

When  the  head  passes  below  the  tendon  of  the  obturator  internus 
and  does  not  secondarily  rise  upon  the  ilium,  the  inversion  and  flexion 
of  the  limb  are  greater  than  when  the  head  comes  to  rest  at  a  higher 
point,  and  may  be  so  great  that  the  limb  crosses  the  opposite  thigh  as 
high  as  its  middle.  The  flexion  may  be  so  masked  by  the  tilting  of  the 
pelvis  that  the  thigh  will  lie  nearly  along-side  the  other,  parallel  to 
the  long  axis  of  the  body,  but  the  condition  can  be  recognized  by 
attention  to  the  compensatory  curve  (lordosis)  of  the  lumbar  vertebrae ; 


BACKWARD  DISLOCATIONS   OF  THE  HIP.  825 

indeed,  Syme  ^  said  lie  made  tlie  diagnosis  of  ischiatic  dislocation  with- 
out other  handling  of  the  patient  than  that  necessary  to  recognize  the 
lordosis. 

The  cause  of  the  comparative  fixation  of  the  limb,  of  its  attitude, 
and  of  the  loss  of  even  passive  abduction  and  external  rotation  was 
first  clearly  shown  by  Bigelow,  in  his  classical  monograph  upon  the 
Hip.  Others  had  recognized,  in  a  measure,  the  part  taken  by  the 
strong  anterior  portion  of  the  capsule  in  determining  the  attitude  of 
the  limb,  but  he  was  the  first  to  study  the  subject  in  all  its  bearings 
and  to  present  a  complete  account  of  the  relations  and  influences  of  the 
Y-ligament  in  all  forms  of  dislocation,  one  which  was  at  once  and  every- 
where accepted  and  has  been  made  the  basis  of  the  present  methods  of 
reduction.  He  says,"  "  The  inversion  is  chiefly  due  to  the  outer  branch 
of  the  Y-ligament,  as  is  shown  by  the  fact  that  the  characteristic  sign 
disappears  when  this  branch  is  divided." 

Diagnosis.  The  recognition  of  the  character  of  the  injury  is  rarely 
difficult.  The  group  of  prominent  symptoms — loss  of  function  ;  adduc- 
tion, inversion,  and  flexion  of  the  limb ;  resistance  to  abduction,  exten- 
sion, and  outward  rotation  ;  elevation  of  the  trochanter  above  Nelaton's 
line — are  not  found  in  any  other  affection  except  perhaps  hip-joint  dis- 
ease of  long  standing.  The  mistake  most  frequently  made  is  that  of 
confounding  it  with  a  fracture  of  the  neck  of  the  femur,  or,  to  speak 
more  definitely,  is  that  of  supposing  a  fracture  of  the  neck  to  be  a 
dislocation.  I  have  met  with  several  instances  of  this,  some  of  which 
led  to  litigation.  The  differences  between  the  symptoms  of  the  two 
injuries  are  striking  and  usually  sufficient  to  make  the  mistake  impos- 
sible if  ordinary  attention  is  paid  to  them  ;  the  fixity  of  the  limb  in  dis- 
location, with  the  knee  thrown  forward  and  inward  against  or  upon  the 
opposite  thigh,  the  prominence  of  the  trochanter,  and,  usually,  its 
increased  distance  from  the  anterior  superior  spine  of  the  ilium,  con- 
trast strongly  with  the  straight,  everted,  powerless  limb  and  flattened 
hip  of  fracture  of  the  neck.  Fractures  with  inversion  and  dislocations 
with  eversion  are  entirely  exceptional.  When  the  two  injuries  have 
coexisted  the  diagnosis  has  sometimes  been  made  by  recognizing  that 
the  head,  which  could  be  felt  out  of  its  place,  did  not  share  in  the 
movements  communicated  to  the  shaft,^  and  sometimes  by  the  splitting 
and  enlargement  of  the  great  trochanter. 

2.  Everted  Dorsal  Dislocations. 

In  this  class,  of  which  there  are  but  few  recorded  cases,  are  here 
included  Bigelow's  anterior  oblique,  everted  dorsal,  and  some  of  the 
supraspinous.  It  is  characterized,  as  the  name  indicates,  by  eversion 
of  the  limb  in  place  of  the  inward  rotation  which  is  so  prominent  a 
feature  of  the  common  dorsal  dislocation,  and  this  symptom  is  due  in 
all  cases,  except  perhaps  the  very  rare  anterior  oblique,  to  rupture  of 
the  outer  branch  of  the  Y-ligament.     In  the  supraspinous  variety  the 

1  Svrae:  London  and  Edinburf,'h  Monthly  .Journal,  1843,  vol.  iii.  p.  498. 

2  Biuelow  :  The  Hip,  )).  38. 

^  Koch  :  Berlin,  klin.  Wochenschrift,  1hh2,  J).  49.2. 


826  DISLOCATIONS. 

head  of  the  bone  lies  above  the  anterior  inferior  spinous  process  of  the 
ilium  in  the  notch  between  it  and  the  superior  spine. 

Although  occasional  cases  had  been  previously  reported,  the  variety 
was  not  described  by  systematic  writers  before  Bigelow,  and  was  not 
even  mentioned  by  Malgaigne,  although  possibly  one  or  two  of  the 
cases  classed  by  him  as  supracotyloid  may  have  been  of  this  kind. 
In  a  paper  by  Blasius^  on  supracotyloid  dislocations  several  cases  of 
this  variety  (everted  dorsal)  are  included,  together  with  others  in  which 
the  head  had  reached  nearly  the  same  position  by  passing  outward  after 
primary  dislocation  forward  and  upward  upon  the  pubis,  and  a  few 
in  which  the  dislocation  was  primarily  directed  upward.  The  same 
grouping  has  been  followed  by  other  writers,  and  in  no  reported  case 
previous  to  1850  does  it  appear  to  have  been  recognized  that  the  head 
had  reached  this  position  by  a  secondary  displacement  after  dislocation 
backward  and  upward.  Blasius's  paper,  although  published  in  1874, 
must  be  classed  with  those  of  an  earlier  period,  for  it  is  really  the 
republication  by  his  son  in  a  graduating  thesis  of  researches  made 
some  time  earlier,  and  it  makes  no  mention  of  Bigelow's  work.  It 
is,  in  one  respect,  a  publication  to  be  regretted,  for  the  authority  of 
its  writer  and  its  date  combine  to  further  the  acceptance  without  exami- 
nation of  the  grouping,  or  classification,  which  cannot  properly  be 
accepted  in  view  of  the  important  pathological  differences  between  the 
individual  cases  of  which  it  is  made  up. 

Cases  reported  before  1850  and  quoted  as  of  this  kind  by  Bigelow 
and  as  possibly  such  in  my  first  edition,  appear  to  me  to  be  more  prob- 
ably dislocations  directly  upward  by  hyperextension  of  the  limb ;  I 
have  recently  seen  such  a  one  the  symptoms  of  which  closely  resem- 
bled those  quoted.     (See  Upward  Dislocations.) 

In  1850  the  possibility  of  the  production  of  this  form  by  trans- 
formation of  a  dorsal  dislocation  was  shown  in  an  attempt  made 
in  the  New  York  Hospital  to  reduce  a  dislocation  "  into  the  sciatic 
notch."  The  case  is  reported  by  Lente;^  after  traction  had  been 
made  and  suddenly  relaxed  the  thigh  was  abducted  and  rotated 
outward,  and  this  brought  the  head  of  the  femur  above  the  acetab- 
ulum, and  below  the  anterior  superior  spinous  process ;  the  shorten- 
ing was  then  about  two  inches ;  the  limb  very  much  rotated  out- 
ward, the  rotundity  of  the  hip  greater  than  that  of  the  other,  and 
the  trochanter  major  one  inch  further  from  the  anterior  superior 
spinous  process. 

Five  years  later  Van  Buren^  observed  in  the  same  hospital  a  case 
which,  so  far  as  I  know,  is  the  first  in  which  the  absence  of  inversion 
and  marked  adduction  was  noted  in  a  case  recognized  as  a  dorsal  dis- 
location. The  limb  "  was  shortened  about  an  inch  ;  the  foot  and  leg 
were  slightly  everted.  This  eversion,  it  was  afterward  ascertained, 
could  be  readily  increased  by  manipulation  ;  but  there  was  an  evident 
obstacle  at  the  hip  to  inversion  of  the  foot.  The  knee  was  slightly 
flexed,  so  that  the  width  of  the  hand  could  be  readily  passed  between 
its  popliteal  aspect  and  the  surface  of  the  bed.     The  obliquity  of  the 

1  Blasius:  Arcli.  fiir  kliii.  Cliir.,  1874,  vol.  xvi.  p.  207. 

2  Lente:  New  York  .loiinial  of  Medicine,  1«5(),  p.  314. 

'  Van  Buren  :  New  York  Medical  Tiine.s,  1856,  vol.  v.  p.  12o,  aud  reprinted  in  his  Con- 
tributions to  Practical  Surgery,  p.  157. 


BACKWARD  DISLOOATIONS  OF  THE  HIP.  827 

femur  toward  its  fellow  was  very  slightly  increased.  Upon  tiie  front 
of  the  thigh  at  its  upper  third  a  very  manifest  concavity  or  sinking  in 
was  noticeable,  the  usual  anterior  convexity  of  the  limb  being  lost. 
The  trochanter  was  about  an  inch  and  a  half  behind  and  above  its  usual 
position,  and,  during  etherization,  it  was  quite  movable  on  attempting 
rotation  of  the  limb.  Finally,  the  head  of  the  femur  could  be  felt 
obscurely  but  pretty  certainly  rotating  in  the  ischiatic  notch,  low  down, 
and  in  contact  with  its  })Osterior  margin.  The  anterior  convexity  of 
the  spine  at  the  loins  was  also  much  increased,  so  that  under  ether 
more  than  the  -width  of  the  hand  could  be  passed  between  it  and  the 
surface  of  the  bed.  Thus  the  case  presented  all  the  classical  features 
of  luxation  into  the  ischiatic  notch,  and  more  than  usually  well  marked, 
with  the  exception  of  adduction  of  the  lower  end  of  the  femur  and 
inversion  of  the  foot."  After  several  failures  to  reduce  by  manipula- 
tion and  traction  downward,  reduction  was  effected  by  traction  while 
the  limb  was  flexed  at  right  angles  to  the  pelvis,  followed  by  abduction 
and  extension. 

In  1864  Symes^  reported  a  case,  and  suggested  for  the  variety  the 
name  of  "  dorsal  with  eversion."  This  was  subsequent  to  Bigelow's 
researches  but  previous  to  his  publication  of  them  except  in  his  lec- 
tures. The  limb  was  shortened  two  inches,  the  foot  extremely  everted, 
the  buttock  flattened,  and  the  head  of  the  femur  tMo  in(;hes  below  the 
anterior  superior  spine  of  the  ilium.  By  flexion  of  the  limb  the  dislo- 
cation was  made  dorsal,  and  a  feature  of  special  interest  is  that  then, 
as  the  limb  lay  untouched  upon  the  table,  eversion  gradually  took  place 
under  the  influence  of  gravity,  and  the  head  returned  to  its  former 
place. 

In  1874  Kocher^  observed  a  similar  case  in  a  woman,  forty-nine 
years  old ;  the  limb  was  fully  extended,  markedly  everted,  and  short- 
ened three  centimetres  ;  the  head  could  be  felt  below  and  to  the  outer 
side  of  the  anterior  superior  spine  of  the  ilium.  By  flexion  and  inward 
rotation  the  dislocation  became  dorsal  with  the  characteristic  symp- 
toms, and  then  by  extension  and  outward  rotation  the  original  symp- 
toms were  reproduced. 

Pathology.  In  a  case  which  I  reported  to  the  New  York  Surgical 
Society,  December,  1887,  and  January,  1888,^  the  head  could  be  dis- 
tinctly felt  below  and  rather  to  the  outer  side  of  the  anterior  superior 
spinous  process ;  the  outer  branch  of  the  Y-ligament  Avas  ruptured  and 
the  muscles  behind  the  trochanter  extensively  lacerated.  Complete 
reduction  was  prevented  by  interposition  of  the  antero-inferior  part  of 
the  capsule. 

Van  Buren's  case,  and  a  very  similar  one  reported  by  Annandalc,* 
show  that  the  head  may  lie  much  further  to  the  outer  side  and  lower. 

Bigelow's    experiments  show  that    this  eversion  depends  upon  the 

rupture  of  the  outer  branch  of  the  Y-ligament.     The   head  of  the 

femur   escapes  at   the   back  of   tiie  joint  while   the    limb    is    flexed, 

adducted,  and  rotated  inward,  and  then  by  external  rotation  the  outer 

branch  is  torn  ;  if,  then,  the  head   remains  in   its  ])osition  o])posite  or 

'  Symes:  Dublin  Quarterly  .Tonrnal  of  the  Medical  Sciences,  ISfil,  vol.  xxxviii.  p.  212. 

2  Kocher:  Volkinaim's  Sanuiiliiiii;  klin.  Vortriipce,  No.  8.'5,  p.  fi.'U. 

^  Stimson  :  New  York  Medical  .luiirnal,  January  aud  February,  1888. 

*  Annandale :  I.ancet,  1870,  vol.  i.  p.  208. 


828 


DISLOCATIONS. 


below  the  sciatic  notch,  the  position  and  symptoms  are  such  as  are 
noted  in  Van  Buren's  and  Annandale's  cases,  the  flexion  and  slight 
adduction  being  due  to  the  remaining  untorn  branch  of  the  ligament. 
The  change  in  the  position  of  the  head  noted  in  the  other  cases  Bige- 
low  was  able  to  reproduce  experimentally  from  a  common  dorsal  dis- 
location by  carrying  the  limb  "  across  the  symphysis,  so  that  the  outer 
and  convex  surface  of  the  socket  shall  correspond  to  the  hollow  beneath 
the  neck  of  the  femur.  With  some  force  the  thigh  can  now  be  everted, 
and  afterward  brought  down  across  the  upper  part  of  its  fellow." 
(This  is  the  form  to  which  he  gave  the  name  "anterior  oblique.") 
"  If,  in  this  position,  it  is  desired  to  bring  the  limb  toward  a  perpen- 
dicular, the  outer  branch  of  the  Y-ligament  must  be  ruptured.     Thus 


Fig.  453. 


Fig.  454. 


Supraspinous  dislocation.  When  the  femur  takes  the 
position  indicated  by  the  dotted  line,  only  the  inner 
branch  of  the  Y-ligament  remains  untorn.    (Bigelow.) 


Anterior  oblique  dislocation. 
Oldnow's  ease. 


liberated,  it  hangs  suspended  by  the  inner  ligament,  and  becomes  capa- 
ble of  lateral  motion  and  of  rotation  ;  and  this  is  probably  the  con- 
dition under  which  supraspinous  luxation,  although  rare,  usually 
occurs." 

Fig.  453  shows  in  the  dotted  lines  the  head  of  the  femur  thus  hooked 
over  the  remaining  part  of  the  ligament. 

The  anterior  oblique  is  a  variety  which  I  feel  some  hesitation  in  pre- 
serving, because  Bigelow  appears  to  have  observed  it  only  in  experi- 
ments upon  the  cadaver,  and  to  have  known  of  only  one  recorded 
case^  in  which  the  attitude  resembled  that  found  in  his  experiments. 
The  specimen  in  that  case  is  represented  in  Fig.  454.  The  mode  of 
production  has  been  quoted  in  the  preceding  paragraph.  The  Y-liga- 
ment is  untorn. 

Symptoms.     The  symptoms  of  the  everted  dorsal  may  be  the  same 

•  Olduow :  Guy's  Hospital  Eeports,  1836,  vol.  i.  p.  97. 


■  SAd^WAltD  DiSLOCAtfONS  OP  THE  HIP.  829 

as  those  of  the  common  dorsal  dislocation,  with  the  exception  tliat 
there  is  marked  or  slight  eversion  of  the  limb  instead  of  inversion  ;  or, 
if  the  head  of  the  femur  has  moved  forward  above  the  anterior  inferior 
spinous  process,  they  may  differ  widely,  for  the  limb  is  then  shortened 
about  two  inches,  slightly  abducted,  more  or  less  everted,  and  fully 
extended.  In  my  case,  a  woman  fifty-five  years  of  age,  the  limb  was 
parallel  with  the  other  and  so  far  everted  that  the  foot  rested  on  its 
outer  border;  it  could  be  adducted  and  flexed  but  not  abducted  or 
rotated  inward.  Shortening  one  and  three-quarter  inches.  By  flex- 
ing and  adducting  the  limb  and  then  rotating  inward  the  attitude  and 
appearance  became  that  of  the  common  dorsal  variety.  Reduction 
was  made  by  flexing  to  a  right  angle,  rotating  inward,  and  then  lift- 
ing. The  patient  died  about  a  month  after  the  accident  (associated 
injuries  and  phthisis).  The  eversion  of  the  limb  is  liable  to  lead 
to  the  mistake  of  supposing  the  injury  to  be  a  fracture  of  the  neck 
of  the  femur,  especially  in  the  cases  in  which  the  limb  is  also 
extended.  The  greater  fixation  of  the  limb  and  the  recognition  of 
the  position  of  the  head  and  of  the  continuity  with  the  shaft,  as  shown 
by  its  sharing  in  the  movements  communicated  to  the  latter,  will  estab- 
lish the  diagnosis. 

The  rupture  of  the  outer  branch  of  the  Y-ligament  is  the  explana- 
tion of  the  inability  noted  in  some  of  the  cases  to  reduce  by  manipu- 
lation alone;  traction  in  the  flexed  position  is  needed  to  bring  the  head 
forward  into  the  socket;  abduction  fails  to  do  it  because  of  the  loss 
of  the  support  of  the  outer  branch  of  the  ligament. 

Treatment  of  Backward  Dislocations. 

The  method  of  reduction  so  long  in  use,  and  which  left  so  many 
dislocated  hips  unreduced,  that  in  which  it  was  sought  to  draw  the 
bone  into  place  by  traction  upon  it  with  compound  pulleys  w^hile  the 
limb  was  almost  fully  extended,  has  at  last  been  abandoned  in  favor 
of  the  methods  of  simple  manipulation  or  of  moderate  traction  in  the 
flexed  position,  or  of  a  combination  of  the  two.  The  advantages  of 
the  flexed  position,  the  possibility  of  reducing  by  the  aid  of  moderate 
traction  when  the  thigh  is  flexed  at  a  right  angle  ^vith  the  trunk,  were 
repeatedly  pointed  out  by  different  writers  during  the  last  century  and 
the  first  half  of  the  present  one  (see  Chapter  XXXIII.),  and  the  pos- 
sibility of  reducing  by  manipulation  alone  (flexion,  outward  rotation, 
and  abduction)  was  also  demonstrated,  but  neither  seems  to  have  had 
any  influence  in  modifying  the  general  practice,  although  some  sur- 
geons, notably  Prof  Nathan  Smith  of  New  Haven,  taught  and  habit- 
ually practised  traction  with  the  limb  flexed  at  a  right  angle,  and  he 
also,  in  l<Sol,  formulated  a  method  by  manipulation  alone. 

Despres,'  in  1835,  independently  fi)rmulated  the  method  by  flexion 
and  outward  rotation;  and  Reid,-  in  1851,  did  the  same,  preceding  the 
flexion  with  marked  adduction  ;  but  they  assumed  that  the  i)rincipal 
obstacle  to  reduction  lay  in  the  resistance  of  the  muscles,  and  their 
manipulations  were  designed  to  overcome  or  avoid  this. 

Bigelow^  quotes  Smith's  description  of  this  method  by  manipulation 

1  Despres:  Bull,  dc  la  Soc.  Anatomiqiio,  Soptcmbor.  is:!5,  p.  1. 

2  Keid  :  Buffalo  Med.  Journ.,  August,  1^51.  •'  BIki-Iow  :   Lancet,  1878,  vol.  i.  p.  S61. 


g30  DISLOCATION. 

from  his  Medical  and  Surgical  Memoirs,  edited  in  1831  by  his  son, 
Nathan  R.  Smith,  as  follows:  "The  first  effort  which  the  operator 
makes  is  to  flex  the  leg  upon  the  thigh,  in  order  to  make  the  leg  a  lever 
with  which  he  may  operate  on  the  thigh  bone.  The  next  movement 
is  a  gentle  rotation  of  the  thigh  outward,  by  inclining  the  foot  toward 
the  ground  and  rotating  the  knee  outward.  Next,  the  thigh  is  to  be 
slightly  abducted  by  pressing  the  knee  directly  outward.  Lastly,  the 
surgeon  freely  flexes  tlie  thigh  upon  the  pelvis  by  thrusting  the  knee 
upward  toward  the  face  of  the  patient,  and  at  the  same  moment  the 
abduction  is  to  be  increased."  Bigelow  adds,  "this  covers  the  ground 
of  priority  of  invention.  It  belongs  to  Nathan  Smith.  ...  In 
1835,  Despres,  and  in  1851,  Reid,  of  Rochester,  enunciated  the  same 
views ;  the  practice  was  good,  but  both  Prof.  Smith  and  Dr.  Reid  based 
the  method  upon  and  sought  its  mechanism  in  its  erroneous  theory  of 
muscular  resistance." 

After  1850  the  attention  of  surgeons  and  anatomists  began  to  be 
directed  more  specifically  to  the  opposition  offered  by  the  untorn  por- 
tions of  the  capsule  and  to  the  position  of  the  rent  in  it,  and  many 
experiments  were  made  upon  the  cadaver  to  obtain  a  more  accurate 
knowledge  of  the  matter.  Among  these  may  be  mentioned  those  of 
Meyer,!  Gunn,^  Roser,^  Bigelow,''  Gelle,'^  Busch,"  and  Tillaux.^  Of 
these  Bi^elow's  researches  were  by  far  the  most  complete  and  accurate, 
and  to  his  classical  work  must  be  referred  the  popularization  and  gen- 
eral acceptance  of  the  views  now  held  and  the  methods  of  treatment 
based  upon  them.  The  importance  of  the  anterior  portion  of  the  cap- 
sule, the  Y-Hgament,  had  indeed  been  specifically  pointed  out  by  one  or 
two  earlier  writers — it  is  mentioned  in  Hyrtl's  Topoc/raphische  Anato- 
mie,  in  Meyer's  paper  in  1850,  and  by  von  Pitha*  in  1863 — but  Bigelow 
was  the  first  to  study  its  influence  in  detail,  to  show  its  constant  action 
in  all  typical  forms,  and  to  base  upon  it  methods  of  reduction  for  the 
different  forms,  and  to  him  belongs  the  credit  not  only  of  independent 
discovery  but  also  of  the  still  more  important  benefit  conferred  by 
impressing  the  facts  upon  the  profession  by  his  careful,  thorough  in- 
vestigations and  his  clear  exposition  of  the  facts  and  principles.^ 

It  is  now  generally  recognized  that  the  chief  obstacle  to  reduction 
is  created  by  the  tension  of  the  Y-ligament  in  the  partly  extended  posi- 
tion of  the  limb,  and  that  this  is  to  be  removed  by  flexion  of  the  limb 
upon  the  trunk.  At  the  same  time  the  movement  of  flexion  brings 
the  head  of  the  femur  down  along  the  back  of  the  acetabulum  so  that 
it  lies  opposite  the  opening  in  the  capsule  if,  as  is  usually  the  case,  it 
has  left  the  socket  at  its  lower  posterior  part  and  has  risen  to  a  higher 

1  H.  Meyer:  Zeitschrift  fur  rat.  Med.,  1850,  vol.  ix.  p.  250. 

2  Gunu :  Penins,  Journal  of  Medicine,  18.53-4,  vol.  i.  p.  97. 
•^  Eoser:  Archlv  fiir  phys.  Heilkuude,  1857,  vol.  i.  p.  42. 

*  Bigelow:  The  Hip,  1869.     Experiments  made  in  1800. 

*  Gelle  :  Arch.  gen.  de  Med.,  1861. 

«  Biisch  :  Arch,  fiir  klin.  Chir.,  1863,  vol.  iv.  p.  11. 

'  Tillaux  :  Bull,  de  la  Soc.  de  Chir.,  1868,  p.  274. 

^  Von  Pitha :  Pitha  and  Billroth's  Chirurgie,  vol.  iv.  part  2.  B,  p.  161. 

^  The  claim  of  priority  in  the  discovery  of  the  part  ]ilayed  by  the  anterior  portion  of 
the  capsule  made  for  Prof.  Gunn,  of  Chicago,  is,  I  think,  sntticiently  answered  by  Prof. 
Bigelow  in  a  letter  published  in  the  Chict'.go  Medical  Examiner,  January,  1870,  p.  25. 


BACKWARD  DISLOCATIONS  OF  THE  HIP.  ^^\ 

level  by  the  subsequent  extension  of  the  limb,  enlarging  the  rent 
upward  in  the  movement ;  if,  more  rarely,  the  head  has  left  the  socket 
at  a  higher  level  while  the  limb  was  only  slightly  flexed,  this  move- 
ment of  flexion  in  reduction,  unless  carried  beyond  a  right  angle,  does 
not  place  the  head  below  the  opening,  or  at  least,  if  it  does  so,  the 
movement  enlarges  the  rent  downward  so  that  the  way  is  still  open 
for  the  return  of  the  head  to  its  place.  Another  reason  for  making 
this  movement  is  found  in  some  cases  in  the  interposition  of  the  obtu- 
rator internus  between  the  head  and  the  socket,  the  cases,  so-called,  of 
"  dislocation  below  the  tendon "  in  which  the  head  has  secondarily 
risen  toward  the  dorsum  ilii.  During  the  movement  the  adduction  and 
internal  rotation  of  the  limb  are  preserved  or  even  somewhat  increased 
in  order  to  lift  the  head  of  the  femur  away  from  contact  with  the  pelvis 
and  from  behind  the  projecting  rim  of  the  acetabulum. 

The  directions  given  by  Bigelow  in  his  first  publication  ^  are  as  fol- 
lows : 

"  Bi/  Traction.  Lay  the  patient,  wdien  etherized,  on  his  back  upon 
the  floor,  bend  the  limb  at  the  knee,  flex  the  thigh  upon  the  abdomen, 
adduct  and  rotate  it  a  little  inward,  to  disengage  the  head  of  the  bone 
from  behind  the  socket.     The  Y-ligament  is  then  relaxed. 

"If  the  bone  can  now  be  abducted  beyond  the  perpendicular,  the 
capsule  and  other  tissues  are  probably  so  torn  or  relaxed  that  reduction 
may  be  accomplished  without  much  difficulty  ;  the  thigh  need  only  be 
forcibly  lifted  or  jerked  toward  the  ceiling,  with  a  little  simultaneous 
circumduction  or  rotation  outward,  to  direct  the  head  of  the  bone 
toward  the  socket." 

In  his  lat(!r  paper  in  the  Lancet,  1878,  he  gives  them  more  briefly 
in  the  following  terms  : 

"  1.  Flex  and  forcibly  lift.     If  this  fails, 

"  2.  Flex  and  lift  while  abducting.  If  this  fails,  it  will  be  found 
that  the  rent  in  the  capsule  has  been  so  enlarged  that  the  first  method 
may  now  prove  successful." 

Bigelow  adds  to  his  first  description  three  other  methods  of  making 
the  manipulation  and  applying  the  force,  and,  although  the  mechanism 
is  the  same  in  all,  the  multiplicity  of  the  directions  has  been  criticised 
by  recent  German  writers,  who  seem  to  regard  the  four  as  essentially 
different  from  one  another. 

Kocher,2  after  making  this  criticism,  describes  what  he  calls  his  own 
method,  and  this  is  quoted  approvingly  by  Albert  and  Kchiig.  Its 
identity  with  Bigelow's  appears  to  me  to  be  complete,  although  it  com- 
bines his  two  methods  by  traction  and  by  manipulation.    It  is  as  follows: 

1.  Inward  rotation  to  relax  the  capsule  and  lift  the  head  from  the 
posterior  surface  of  the  pelvis. 

2.  Flexion,  to  a  right  angle  and  gently,  preserving  the  existing 
adduction  and  inward  rotation. 

3.  Traction,  to  make  the  capsule  tense,  so  that  it  can  be  utilized  in 
the  following  movement,  and  to  raise  the  head  to  the  level  of  the 
acetabular  margin,  thus  overcoming  the  action  of  gravity. 

1  P.ificlow :  Loc.  cit.,  p.  46. 

^  Volkuiaun's  klinische  Vortriige,  No.  ti3. 


832 


MSLOCATlom. 


4.  Outward  rotation  ;  tliis  makes  the  posterior  part  of  the  capsule 
and  outer  band  of  the  Y -ligament  tense,  and  turns  the  head  forward 
into  the  socket. 

There  are  a  number  of  practical  points  connected  with  the  carrying 
out  of  these  directions  which  require  attention.  The  pelvis  may  need 
to  be  steadied  or  immobilized  during  traction,  in  order  that  the  limb 
mav  not  be  too  soon  or  unwittingly  abducted,  and  this  may  be  done 
either  by  the  hands  of  assistants  or  by  the  pressure  of  the  surgeon's 

Fig.  455. 


Reduction  of  dorsal  dislocation  of  the  hip  by  the  weight  of  the  limb. 

foot  upon  the  anterior  superior  spinous  process  of  the  ilium  of  the 
injured  side  while  he  is  lifting  the  thigh. 

Tlie  traction  upon  the  thigh  may  be  made  by  the  hands  of  the  sur- 
geon, but  if  the  patient  is  a  muscular  adult  the  force  that  can  be  thus 
exerted  may  be  insufficient,  and  it  can  then  be  conveniently  supple- 
mented by  passing  a  bandage  tied  in  a  long  loop  under  the  patient's 
flexed  knee  and  over  the  surgeon's  shoulders ;  this  leaves  his  hands 
free  to  rotate  the  thigh  by  means  of  the  leg.  It  is  important  to  remem- 
ber that  reduction  is  to  be  made  by  traction,  not  by  manipulation,  for 
if  the  thigh  falls  backward  by  its  own  weight  or  is  pressed  back  by 
the  surgeon  while  he  is  "manipulating"  it  may  seriously  change  its 
relations  with  the  tissues  about  it. 


BACKWARD  DISLOCATtONS  OF  THE  HIP.  833 

A  much  more  convenient  plan,  one  which  I  have  habitually  em- 
ployed for  many  years/  is  to  place  the  patient  face  downward  upon  a 
table  with  his  legs  projecting  so  far  beyond  the  edge  that  the  injured 
thigh  hangs  directly  downward  while  the  surgeon  grasps  the  ankle, 
the  knee  being  flexed  at  a  right  angle  (Fig.  455).  The  other  limb  is 
held  horizontal  by  an  assistant.  The  weight  of  the  limb  now  makes 
the  needed  traction  in  the  desired  direction,  and  the  surgeon  has  only 
to  wait  for  i\\Q  muscles  to  relax  and  the  bone  to  resume  its  place  with- 
out further  effort  on  his  part  than  a  slight  rocking  or  rotation  of  the 
limb.  Occasionally  I  have  added  the  weight  of  a  small  sand-bag  at 
the  knee  or  have  made  sudden  slight  pressure  at  the  same  point.  It 
will  often  succeed  without  anaesthesia  and  sometimes  so  quietly  that 
there  is  no  jar  or  sound  indicating  the  return  to  place.  In  only  two 
cases  has  it  failed  in  my  hands ;  both  were  then  reduced  by  traction  in 
the  axis  of  the  partly  flexed  limb.  I  presume  that  in  both  the  bone 
had  left  the  socket  at  its  upper  posterior  segment — "  iliac  "  dislocation. 

If  manipulation  alone  is  used  external  rotation  must  be  carefully 
avoided  during  the  first  steps,  lest  it  should  convert  the  dislocation  into 
an  everted  dorsal  by  throwing  the  head  forward  above  the  socket ;  and 
extreme  flexion  and  abduction  without  simultaneous  traction  are  also  to 
be  avoided,  in  order  to  escape  the  conversion  of  the  dislocation  into  one 
upon  the  obturator  foramen  by  the  passage  of  the  head  below  the  socket. 

The  everted  cZor.s-a^  dislocations  are  reduced  after  having  first  converted 
them  into  the  dorsal  form.  This  conversion  is  effected  by  flexion  and 
inward  rotation,  with  adduction,  if  necessary,  to  make  room  for  the 
head  of  the  bone  to  slide  upon  the  ilium;  the  rupture  of  the  outer 
branch  of  the  Y-ligaraent  deprives  the  operator  of  much  of  the  advan- 
tage of  rotation,  and  the  dislocation  must,  therefore,  be  reduced  by 
direct  traction  toward  the  socket,  with  local  guidance  of  the  head.  In 
my  own  case,  in  which,  after  conversion  into  the  dorsal  form  the 
tendency  of  the  head  again  to  pass  forward  above  the  acetabulum  was 
very  marked,  outward  rotation  had  to  be  carefully  avoided. 

The  possibility  of  fracturing  the  neck  of  the  femur  during  manipu- 
lation must  be  borne  in  mind  (see  Chapter  LIIL). 

^  Stimson  :  New  York  Medical  Journal,  August  3,  1889. 


CHAPTER    LII. 

DISLOCATIONS  OF   THE  HIP.— (Coktinued.) 

Dislocations  Downward  and  Inward:  Obturator,  perineal — Forward  and  Up- 
ward :  Suprapubic,  iliopectineal — Upward  :  Subspinous,  supracotyloid — 
Downward  on  the  Tuberosity  of  the  Ischium. 

DISLOCATIONS    DOWNWARD    AND    INWARD. 

1.  Obturator  or  thyroid  dislocations,  or  dislocations  upon  the 
thyroid  foramen  ;  and  2,  perineal  dislocations. 

In  this  class  of  dislocations  the  head  of  the  femur  leaves  the  socket 
at  its  lower,  or  lower  and  inner,  part,  and  passes  forward  and  inward 
to  rest  upon  the  obturator  foramen  (obturator  dislocation),  or  passes 
still  further,  and,  crossing  the  ischio-pubic  ramus,  projects  in  the  per- 
ineum (perineal  dislocation).  The  limb  is  flexed,  abducted,  and  usually 
rotated  outward. 

Obturator  or  Thyroid  Dislocations. 

These  dislocations,  although  infrequent,  are  apparently  the  second  in 
order  of  frequency  of  those  of  the  hip,  and  it  seems  not  improbable 
that  this  form,  in  part  at  least,  is  the  first  stage  in  the  production  of 
some  of  the  suprapubic,  and  even  some  of  the  dorsal  dislocations  ;  that  is, 
the  head  of  the  bone,  having  left  the  socket  at  its  lowest  part  in  forced 
flexion  of  the  limb,  may  either  be  turned  backward  behind  the  acetab- 
ulum by  adduction,  internal  rotation,  and  diminution  of  the  flexion,  or 
forward  and  upward  upon  the  pubis  by  external  rotation  and  extension  ; 
the  obturator  form  is  produced  by  its  passage  more  directly  forward  and 
inward  upon  the  obturator  foramen  by  abduction  and  external  rotation. 

Cause.  The  commonest  cause  appears  to  be  great  violence  acting 
upon  the  back  of  the  pelvis  while  the  limb  is  flexed  and  abducted,  as 
in  the  fall  of  a  heavy  object  upon  the  back  of  a  man  who  is  stooping 
forward  with  his  legs  separated.  Simple  abduction  of  the  extended 
limb  is  apparently  sufficient  to  produce  the  injury,  as  is  shown  by  a 
case  reported  by  Corne,'  in  which  the  thigh  of  a  drunken  soldier  was 
forcibly  abducted  by  his  comrades.  In  a  case  reported  by  Keate,^  and 
another  by  Barker,'^  the  mechanism  was  apparently  the  same ;  in  the 
former  the  patient,  while  riding,  fell  into  a  ditch,  his  horse  falling  upon 
him  and  widely  separating  his  legs;  the  head  of  the  femur  lay  close 
to  the  tuber  ischii.  In  the  latter  the  patient  fell  from  a  height  of 
about  thirty  feet,  striking  upon  a  sandbank  and  having  his  legs  widely 
separated  ;  both  thighs  were  dislocated. 

In  another  set  of  cases  it  is  difficult  to  determine  whether  the  cause 
has   been  direct  impulsion  of  the  head  of  the  femur  downward  and 

1  Corne:  Recueil  de  Mm.  de  Med.  Mil.,  February,  1867,  quoted  by  Lossen. 

2  Keate  :  London  Medical  Gazette,  vol.  x.  p.  19,  "quoted  by  Bigelow. 

3  Barker;  American  Journal  of  the  Medical  fciciences,  1854,  vol.  xxvii.  p.  412. 

( 834  ) 


THYROID  DISLOCATIONS  OF   THE  HIP. 


835 


inward  by  a  force  acting  on  the  outer  side  of  the  great  trochanter,  or 
whether  it  has  been  exaggerated  abduction  by  pressiu-e  forward  of  the 
outer  part  of  the  pelvis,  as  in  a  case  reported  by  Treub,^  in  which  a 
man  while  l\ing  on  his  face  was  run  over  by  a  wagon,  the  wheels  pass- 
ing obliquely  across  his  left  hip  at  the  level  of  the  trochanter  and  the 
peh'is  from  left  to  right,  and  received  a  dislocation  of  the  left  hip. 

Pathology.  The  reported  autopsies  in  recent  cases  are  very  few.- 
They  show  rupture  of  the  capsule  on  the  inner  and  lower  side,  usually 
near  the  acetabulum  and  sometmies  extending  along  the  neck,  and 
laceration  of  the  obtiu-ator  externus  and  pectineus.  Sometimes  the 
obturator  is  pushed  before  the  head  of  the  bone.  In  one  case  (Duboue) 
the  femoral  vein  was  torn.  The  head  of  the  femur  rests  on  the  obtu- 
rator foramen  or  on  the  ramus  beyond  it.  In  a  recent  one  of  my  own 
the  ligamentum  teres  was  untorn ;  in  another^  it  was  torn  at  its  femoral 
insertion,  there  was  a  ragged  rent  in  the  capsule  by  the  cotyloid  notch,  and 
slight  laceration  of  the  obturator  externus  and  adductor  magnus.  In  a 
case  reported  by  Werner*  the  ascending  ramus  of  the  ischium  was  broken. 
In  a  six-months-old  case  Dollinger  found  the  lower  outer  portion  of 
the  rim  of  the  acetabulum  broken  off  and  so  firmly  attached  within 
the  cavity  that  its  removal  stripped  the  cartilage  from  the  latter. 

Several  specimens  of  old  dislocation  have  been  examined:  those  of 
Moreau  and  Stanski,  quoted  by  IMalgaigne,  Cooper,"^  and  Sedillot.^ 
In  these  the  head  occupied  the  foramen  ovale  more  or  less  com- 
pletely', and  a  new  socket  had 
been  formed  by  the  growth  of 
bone  around  it;  in  Cooper's  case 
the  head  was  so  completely  en- 
closed by  this  new  socket  that 
it  could  not  be  removed  from  it 
without  breaking  its  edge,  and 
yet  it  was  freely  movable  and 
was  covered  with  articular  carti- 
lage. In  Stanski's  the  Y-liga- 
ment  had  been  completely  trans- 
formed into  bone,  and  the  head 
of  the  femur  lay  near  the  tuber- 
osity of  the  ischium,  the  limb 
being  much  flexed  and  abducted. 
In  Sedillot's  the  head  of  the 
femur  was  atrophied  and  ir- 
regular, but  the  limb  was  so 
serviceable  that  the  patient  was 
a  professional  soldier,  and  shared 
in  all  the  campaigns  of  the  army. 

Experiments  upon  the  cadaver  corroborate 


Fig.  456. 


Obturator  dislocation.     (BuiELOW.) 


the  clinical   and   post- 


'  Treub:  Cfintralblatt  fiir  r'hirur<;ie,  1SS2,  p.  720. 

2  Verhtu'she,  Gazette  fk's  Hopitaux,  1S.')1,  p.  2S:^;  ScliiiiziiiKcr,  Wiener  nied.  Pre.s.se. 
1880,  No.  '.i,  quoted  bv  Poiii.sot ;  Curling,  Medical  Times  and  Gazette,  lS,'5:i,  vol.  u, 
p  423-  Duboue,  Bull.  <fe  la  Soeiete  Anatoniiquc,  1JS.5S,  p.  41)(i;  Annandale,  British  Medical 
Journal,  1870,  vol.  i,  p.  101.  ^  Bolton:  .\nnals  of  Surgery,  October,  1902,  p.  586. 

•"Werner:  Beitriige  zur  klin.  Chir..  vol.  xli. 

6  Cooper:  Loc.  cit.,  p.  50.  «Sedillot:  Gazette  des  Hopitaux,  1601,  x,  p.  94. 


836  DISLOCATIONS. 

mortem  data  concerning  both  the  pathology  and  the  mode  of  produc- 
tion. If  the  dislocation  is  produced  by  abduction  of  the  extended 
limb  the  rent  in  the  capsule  is  found  to  lie  on  the  inner  side  of  the 
joint,  while,  when  it  is  produced  by  abduction  and  outward  rotation 
following  flexion,  or  by  transformation  of  a  primary  dorsal  dislocation, 
the  rent  is  mainly  on  the  under  side,  and  its  extension  in  front  and 
upward  is  effected  by  secondary  displacement  of  the  head.  The 
Y-ligament,  remaining  untorn,  keeps  the  limb  partly  flexed,  abducted, 
and  everted,  the  head  of  the  femur  rests  against  the  inner  and  lower  side 
of  the  acetabulum,  and  is  prevented  from  rising  by  its  pressure  against 
this  part  of  the  bone  and  by  the  untorn  portion  of  the  capsule  above. 

A  case  of  compound  dislocation  has  been  quoted  in  Chapter  LI. 

In  a  case  reported  by  Cooke  ^  the  shaft  of  the  femur  was  also  broken 
just  below  the  trochanters;  the  patient  was  a  boy  nine  years  old,  and 
the  injury  was  caused  by  a  fall.  Probably  the  dislocation  was  first 
produced,  and  then  the  bone  was  broken  by  a  continuation  of  the  force, 
or  by  a  second  blow.  Reduction  was  easily  effected  by  direct  pressure 
on  the  head,  and  the  patient  made  a  good  recovery. 

Symptoms.  The  limb  is  flexed,  abducted,  and  usually  rotated  out- 
ward, and  it  appears  to  be  elongated  because  the  foot  is  projected  and 
brought  to  the  ground  by  a  compensatory  tilting;  of  the  pelvis  forward 
and  downward  on  the  same  side  (Figs.  457,  458).  The  trochanteric 
region  is  flattened,  and  the  trochanter  lowered  and  displaced  inward ; 
the  adductors  are  usually  tense.  The  outward  rotation  of  the  limb  is 
not  marked  and  may  be  absent,  or  there  may  even  be  some  inward 
rotation. 

The  statements  concerning  the  comparative  length  of  the  limbs  on 
measurement  are  contradictory,  presumably  because  of  the  failure  of 
some  observers  to  place  the  two  limbs  in  symmetrical  positions,  or 
because  of  the  greater  or  less  abduction  and  flexion  of  the  limb  when 
measured.  Tluis,  in  marked  flexion  and  abduction  measurement  from 
the  anterior  superior  spine  of  the  ilium  to  the  knee  or  ankle  will  show 
shortening  of  the  injured  limb;  while,  if  the  limb  is  extended  and  but 
slightly  abducted  the  measurement  may  show  an  actual  elongation. 

The  head  of  the  femur  may  be  more  or  less  distinctly  felt  on  deep 
pressure  toward  the  obturator  foramen  from  the  inner  side.  The 
statement  occasionally  made  that  the  head  can  be  felt  to  move  by  the 
finger  in  the  rectum  pressed  against  the  inside  of  the  foramen  when 
the  limb  is  rotated  is  an  error  of  observation.  The  same  sensation  can 
be  obtained  when  the  joint  is  not  dislocated,  and  is  due  to  the  alter- 
nate stretching  and  relaxation  of  the  obturator  internus  during  the 
movement. 

Sometimes  the  patients  have  been  able  to  walk  quite  well  immedi- 
ately after  the  accident,  and  some  of  them  have  not  sought  advice 
until  after  the  lapse  of  several  days.  S^dillot  states  that  this  was  so  in 
three  of  the  five  cases  which  he  had  seen,  and  one  of  the  patients  came 
to  him  only  because  he  noticed  that  he  could  not  completely  adduct 
the  limb. 

The  diagnosis  of  the  dislocation  and  of  the  variety  is  made  by 
1  Cooke  :  Lancet,  1864,  vol.  i.  p.  37. 


THYROID  DISLOCATIONS  OF  THE  HIP. 


837 


attention  to  the  attitude  and  fixation  of  the  limb,  the  impossibility  of 
completely  extending  and  adducting  it,  the  elongation  in  the  extended 
position,  the  depression  of  the  trochanter,  and  the  presence  of  the  head 
of  the  femur  in  its  new  position. 


Fig.  457. 


Fig.  458. 


Obturator  dislocation.    (Stimson.) 


Obturator  dislocation.    (John.son.) 


Treatment.  Bigelow,  in  his  original  ])apcr,  gives  ten  procedures  for 
reducing  thyroid  and  downward  dislocations,  which  may  be  grouped 
as  four  different  methods  :  1,  mani])ulati()n  ;  2,  traction  in  tlie  axis  of 
the  flexed  and  abducted  limb  ;  3,  traction  outward  against  the  npj)er 
part  of  the  thigh  ;  4,  transformation  into  a  dorsal  di.slocation,  and 
reduction   as   such.     In    his  last  paper  ^  he  seems  to  prefer  the  last 

'  Bigelow :  Lancet,  1878,  vol.  i.  p.  861. 


DISLOCATIONS. 


Fig.  459. 


method,  adducting  the  thigh  in  order  to  carry  the  head  to  the  dorsum 
and  enlarge  the  opening  in  the  capsule,  and  then  reducing  by  flexion 
and  forcible  lifting  of  the  head  toward  the  socket. 

His  directions  ^  for  reducing  by  manipulation  are  :  "  Flex  the  limb 
toward  a  perpendicular,  and  abduct  it  a  little  to  disengage  the  head 
of  the  bone ;  then  rotate  the  shaft  strongly  inward,  adducting  it,  and 
carrying  the  knee  to  the  floor.  The  trochanter  is  then  fixed  by  the 
Y-ligament  and  the  obturator  muscle,  which  serve  as  a  fulcrum. 
AVliile  these  are  wound  up  and  shortened  by  rotation  (Fig. 459),  the 

descending  knee  pries  the  head  upward 
and  outward  to  the  socket.  ...  In 
this  manceuvre  the  action  of  the  liga- 
ment may  be  aided,  if  necessary,  by  a 
towel  passed  round  the  head  of  the 
femur  to  draw  it  upward  and  outward. 
Rotation  outward  may  be  substituted 
for  inward  rotation." 

The  clinical  histories  show  that  in- 
ward and  outward  rotation  have  suc- 
ceeded, each  after  the  other  has  failed, 
and  that  the  former  is  quite  likely  to 
transform  the  dislocation  into  a  posterior 
one  ;  as  outward  rotation  most  surely 
prevents  this  change,  surgeons  appear 
now  to  prefer  it.  The  directions  given 
by  Kocher,^  and  approvingly  quoted  by 
the  German  surgeons,  are  as  follows  : 

1.  Flexion  of  the  thigh  to  a  right  angle  with  the  pelvis,  while 
preserving  the  abduction  and  outward  rotation  in  which  the  limb  is 
found.     This  leaves  all  parts  of  the  capsule  relaxed. 

2.  Traction,  to  make  the  posterior  part  of  the  capsule  tense,  and  to 
bring  the  head  nearer  tlie  socket. 

3.  Outward  rotation,  which,  acting  through  the  tense  posterior  por- 
tion of  the  capsule  and  outer  branch  of  the  Y-ligament,  brings  the 
head  upward  and  backward  into  place. 

Direct  pressure  or  traction  outward  upon  the  upper  part  of  the  thigh 
has  often  proved  a  valuable  aid,  either  by  directly  moving  the  head  of 
the  femur  toward  the  socket  or  by  furnishing  a  fulcrum  by  means  of 
wiiich  the  head  could  be  moved  in  this  direction  by  adducting  the 
knee.  One  of  Bigelow's  procedures,  for  example,  is  to  place  the 
])atient  "  in  a  sitting  posture  with  a  log,  or  post,  or  bedpost  between 
liis  thighs,  and  pry  the  head  outward  over  this  fulcrum  by  means  of 
the  long  shaft  of  the  femur." 

My  own  cases  have  been  easily  reduced,  under  ether,  by  increasing 
the  flexion  and  rotation,  making  traction  in  the  long  axis  of  the  limb, 
and  then  lowering  and  rotating  inward  or  back  and  forth. 

Kocher''*  reduced  a  dislocation  of  four  weeks'  standing,  which  had 
resisted  all   other  methods,  by  making  continuous  traction  in  the  axis 


Reduction  of  obturator  dislocation  by 
rotation ;  showing  tlie  mechanism  of  the 

(BiGELOW.) 


manceuvre. 


1  Bigelow  :  The  Hip,  p.  79. 
•'  Kocher :  Loc.  cit.,  p.  620. 


-  Kocher;  Volkmann's  kliii.  Vortrage,  No.  83. 


THYROID  DISLOCATIONS  OF  THE  HIP.  839 

of  the  limb  and  combining  with  it  elastic  traction  laterally  on  the 
upper  part  of  the  thigh.  On  the  morning  of  the  fourth  day  reduction 
was  found  quietly  to  haye  taken  place. 

In  a  case  in  which  the  dislocation  had  existed  for  twenty  months 
and  the  disability  was  great,  MacCormac  excised  the  head  and  tro- 
chanter Ayith  a  good  result.  The  patient  was  a  sailor  nineteen  years 
old.     For  details  of  the  case  (see  Chapter  LIII.). 

Perineal  Dislocations. 

The  recorded  cases  of  this  form  are  not  numerous.^  It  is  character- 
ized by  the  presence  of  the  head  more  superficially  placed  than  in  the 
obturator  yariety  and  displaced  to  a  greater  distance  from  the  socket, 
so  as  even  in  one  case  to  press  upon  the  urethra  and  interfere  with  the 

Fig.  460. 


Perineal  dislocation  of  hip.    (Stimson.) 


voiding  of  the  urine.  In  Taylor's  case,  quoted  aboye  among  compound 
dislocations  of  the  hip,  page  812,  the  di.slocation  was  made  conqwund 
by  a  rent  in  the  integument  of  the  perineum  nearly  two  inches  long  ; 
and,  possibly,  Woodward's  case,  quoted  in  the  same  section,  may  be 
looked  upon  as  an  extreme  form  of  this  variety. 

The  cause  appears  to  be  extreme  abduction  of  tlic  limb,  caused  in 
my  three  cases  by  the  fall  of  a  licayy  body  upon  the  patient's  back  as 
he  stood  or  knelt  with  tiie  thigh  flexed  and  abducted.      Probably  the 
»  See  also  a  paper  by  Riedeuger  in  Muncli.  mcd.  Wocbensclirift,  August  16,  1892. 
58 


840  DISLOCATIONS. 

capsule  is  widely  torn,  and  thus  may  be  explained  the  varying  attitude 
of  the  limb  in  respect  of  inversion  or  e version.  In  an  autopsy  reported 
by  Shaw '  not  only  was  the  capsule  extensively  detached  at  its  inner 
and  posterior  insertion  upon  the  acetabulum,  but  also  the  iliofemoral 
ligament  was  partly  separated  from  the  neck  of  the  femur,  and  a  small 
rent  extended  from  that  point  into  the  capsule. 

In  my  three  cases  ^  the  thigh  was  flexed  and  abducted  so  that  it  stood 
far  out  from  the  side  of  the  body,  making  an  angle  of  between  60  and 
70  degrees  with  the  sagittal  and  frontal  planes  (Fig.  460).  When  the 
other  limb  was  placed  as  nearly  as  possible  in  the  corresponding  posi- 
tion (the  same  degree  of  abduction  could  not  be  obtained)  the  distance 
between  the  knees  was  thirty  inches,  and  measurement  from  the  ante- 
rior superior  spine  to  the  knee  showed  from  one  and  a  half  to  four 
centimetres  shortening.  A  rounded  mass,  the  head  of  the  femur, 
could  be  felt  beginning  one  inch  from  the  mid-line  of  the  perineum 
and  extending  forward  to  the  adductor  longus  and  backward  nearly  to 
the  level  of  the  anus.  Adduction  and  extension  painful  and  opposed; 
slight  additional  flexion  and  rotation  possible.  All  w^ere  easily  reduced 
by  the  method  given  above,  flexion  and  traction. 

Theoretically  reduction  should  be  most  readily  effected  by  traction 
in  the  axis  of  the  abducted  limb  and  by  direct  pressure  upon  the  head 
of  the  bone  or  upon  the  upper  part  of  the  shaft,  anaesthesia  being  used 
to 'prevent  opposition  by  the  muscles.  The  extensive  laceration  of 
the  capsule  and  ligaments  would  probably  make  purely  manipulative 
methods  ineffective. 

DISLOCATIONS   UPWARD   AND   FORWARD,  AND   INWARD  AND 
FORWARD.     SUPRAPUBIC. 

Iliopectineal.    Pubic.    Intrapelvic. 

In  these  dislocations  the  head  of  the  femur  comes  to  rest  upon  the 
superior  ramus  of  the  pubis,  either  at  the  iliopectineal  eminence  above 
and  a  little  to  the  inner  side  of  its  normal  position  (iliopectineal),  or, 
more  rarely,  nearer  the  symphysis  pubis  (pubic).  On  the  one  side  the 
position  merges  into  that  of  the  supracotyloid,  and  on  the  other  into 
that  of  the  obturator.  Some  of  the  iliopectineal,  in  which  the  head  has 
remained  very  close  to  the  anterior  inferior  spine  of  the  ilium,  have  been 
described  by  their  reporters  and  others  under  the  name  supracoti/Ioid, 
and  some  writers  describe  the  pubic  variety  as  a  variety  of  the  obtu- 
rator, or,  rather,  of  a  class  to  which  they  give  the  name  pneglenoid  or 
dislocations  forward  and  inward.  Exceptionally  the  head  may  pass 
under  or  through  Poupart's  ligament  and  rest  in  the  iliac  fossa,  the 
inti-apelviG  or  suprapectineal  dislocations. 

The  head  of  the  bone  may  leave  the  socket  at  its  upper  and  inner 
part,  and  in  this  case  it  appears  probable  that  the  head  rests  on  the 
iliopectineal  eminence,  or  it  may  leave  it  at  a  somewhat  lower  point 

^  Shaw :  Transactions  of  the  Pathological  Society  of  Londou,  1859,  vol.  x.  p.  211. 
2  For  full  details  of  two  see  New  York  Medical' Journal,  August  3,  1889;  the  third  is 
shown  in  Fig.  460. 


SUPRAPUBIC  DISLOCATIONS  OF  THE  HIP.  841 

and  pass  inward  and  forward  to  the  symphysis,  or  it  may  pass  at  first 
inward  and  downward  across  the  obturator  foramen  while  the  limb  is 
flexed,  and  then  move  upward  to  rest  upon  the  upper  and  front  surface 
of  the  superior  ramus  of  the  pubis  as  the  limb  is  subsequently  low- 
ered. It  is  to  be  remembered  that  the  upper  border  of  the  symphysis 
pubis  is  a  little  below  the  level  of  the  centre  of  the  cotyloid  cavity  in 
the  upright  position. 

In  correspondence  with  these  differences  in  the  position  taken  by  the 
head  are  found  diiferences  in  the  mode  of  production,  according  as  the 
head  is  moved  more  directly  upward,  upon  the  iliopectineal  eminence, 
by  hyperextension  of  the  limb,  or  is  first  turned  more  directly  forward 
by  outward  rotation  and  abduction  and  then,  after  rupture  of  the  ante- 
rior and  inner  part  of  the  capsule,  is  pressed  upward  or  inward.  Of 
the  former  there  are  a  luimber  of  clinical  examples  in  which  the  limb 
itself  has  been  hyperextended,  or,  more  commonly,  the  trunk  has  been 
violently  pressed  backward  while  the  limb  was  fixed  ;  thus,  a  man  steps 
into  a  hole  and  falls  backward  ;  another,  wrestling,  is  forcibly  bent 
backward  by  his  antagonist.  Of  the  latter,  outward  rotation  and 
abduction,  the  clinical  instances  are  not  so  clear,  but  the  possibility  of 
the  production  in  this  manner  has  been  fully  proved  by  experiment 
upon  the  cadaver ;  a  muscular  woman/  carrying  a  keg  of  potatoes  on 
her  back,  stumbled  and,  to  avoid  a  fall  forward,  threw  her  body  with 
a  twisting  movement  backward  ;  a  man  ^  while  swimming  made  a  vigor- 
ous thrust  with  his  legs  and  felt  a  sharp  pain  in  the  groin  ;  he  was  still 
able  to  walk,  though  with  much  difficulty,  and  on  examination  a  dislo- 
cation upon  the  pubis  was  found. 

Pathology.  The  pathology  has  been  shown  by  several  autopsies  in 
recent  and  old  cases.  Aubry  ^  found  the  capsule  torn  along  its  anterior 
half  near  its  insertion  upon  the  acetabulum  ;  the  psoas  and  the  crural 
nerve  crossed  the  front  of  the  neck  ;  the  head  of  the  femur  lay  between 
the  psoas  and  pectineus,  raising  the  latter  and  the  vessels ;  there  was 
an  interval  of  two  centimetres  between  it  and  the  anterior  inferior 
spinous  process  of  the  ilium.  Roser*  found  the  rent  in  the  front  of  the 
capsule  extending  from  the  anterior  inferior  spinous  process  down  to 
the  notch  ;  the  psoas  and  iliacus  were  pushed  outward,  and  the  vessels 
crossed  the  head;  the  small  external  rotators  were  drawn  inward  and 
pressed  into  the  acetabulum  by  the  great  trochanter.  Albert  (loc.  cit., 
p.  276)  found  the  head  resting  against  the  outer  side  of  the  iliopectineal 
eminence  and  covered  on  its  inner  half  by  the  psoas  and  iliacus;  when 
it  was  pressed  further  upward  the  muscle  lay  across  its  neck.  The 
iliopectineal  fascia  (the  deeper  part  of  the  sheath  of  the  vessels)  was 
untorn,  but  nevertheless  the  artery  was  displaced  outward  by  the  head 
so  that  it  rested  across  its  centre  and  curved  outward  immediately 
l)e]ow  Poupart's  ligament ;  the  capsule  was  torn  above  and  in  front 
for  about  one-third  of  its  circumference,  the  greater  part  of  the  ilio- 
femoral ligament  being  uninjured ;  the  ligamentum  teres  was  torn 
away  at  its  insertion  upon  the  head,  and  the  cartilaginous  rim  of  the 
acetabulum  was  entirely  uninjured  ;  the  posterior  i-otators  were  relaxed 

1  Albert :  Chirurgie,  vol.  iv.  p.  271.  ^  Ure  :  Lancet,  1857,  vol.  ii.  \>.  170. 

3  Aiibi-y:  Bull,  de  la  Societc  dc  Chinirgie,  1853,  vol.  iii.  p.  377. 
*  Eoser:  Arch,  fiir  phj-s.  Heilkunde,  1857,  vol.  i.  p.  58. 


842  DISLOCA  TIONS. 

Kocher  ^  found  the  capsule  torn  along  its  anterior  half  close  to  its  inser- 
tion upon  the  femur,  the  portion  which  remained  attached  to  the  acetab- 
ulum hanging  as  a  flap  between  the  head  and  the  socket ;  the  psoas  and 
iliacus  were  stretched  across  the  neck  of  the  bone,  and  the  vessels  lay 
to  the  inner  side  of  the  head ;  the  ligamentum  teres  was  torn  away 
near  its  attachment  to  the  acetabulum,  and  the  cartilaginous  rim  of  the 
socket  was  uninjured. 

Borchard  ^  reports  a  case  with  avulsion  of  the  great  trochanter  and 
a  hernia  beneath  the  detached  Poupart's  ligament,  and  cites  a  similar 
case  reported  by  Lauensteiu, 

In  a  case  reported  by  Stokes '  in  which  the  head  had  passed  over  the 
brim  into  the  pelvis,  the  superior  ramus  of  the  pubis  had  been  frac- 
tured and  much  comminuted.  The  patient  died  on  the  table  immedi- 
ately after  reduction,  by  pulmonary  embolus,  it  was  thought. 

Cases  in  which  the  dislocation  was  compound  have  been  quoted  in 
Chapter  LI.,  p.  811;  in  one  of  them  the  femoral  vein  was  ruptured. 
In  a  case  reported  by  Goldsmith  and  quoted  on  p.  496,  in  which 
the  dislocation  had  remained  unreduced  for  two  months  when  the 
patient  came  under  observation,  there  was  found  a  diffused  pulsating 
swelling  occupying  the  iliac  fossa  and  extending  down  to  the  middle 
of  the  thigh,  which  had  appeared  a  few  days  after  the  accident ;  the 
external  iliac  artery  was  tied,  and  at  the  patient's  death,  five  days 
later,  the  femoral  and  external  iliac  arteries  were  found  to  be  perforated 
for  the  distance  of  an  inch  on  their  postero-external  aspect,  and  the 
head  of  the  femur  lying  in  the  cavity  of  the  aneurism. 

Fig.  461. 


Old  unreduced  suprapubic  dislocation  of  the  hip.    (Cooper.) 

In  one  or  two  cases  pressure  upon  the  anterior  crural  nerve  has  been 
manifested  by  numbness  in  its  area  of  distribution, 

1  Kocher :  Loc.  cit.,  p.  616.       2  Borchard  :  Deutsche  Zeitschrift  fur  Chir.,  vol.  Isvi.  p.  572. 
*  Stokes:  British  Medical  Journal,  1880,  vol.  ii.  p.  916. 


SUPRAPUBIC  mSLOCATIOXS  OF  THE  HIP. 


843 


A  case  treated  by  Brausby  Cooper  ^  and  examined  after  death  at  the 
end  of  three  weeks  is  reported  in  detail,  but  it  is  not  clear  how  much 
of  the  laceration  of  the  muscles  was  due  to  the  dislocation  and  how 
much  to  the  repeated  attempts  to  reduce  it.  "  The  anterior  part  [of 
the  capsule],  where  crossed  by  the  tendons  of  the  psoas  and  iliacus 
muscles,"  was  the  only  part  untorn  ;  the  head  of  the  femur  lay  in  the 
groin  on  the  inner  side  of  the  great  vessels  and  above  tiie  internal 
circumflex  artery. 

In  an  old  case  examined   by  Sir  Astley  Cooper '   "  the  head  of  the 
thigh   bone   had  torn   up   Poupart's   ligament,  so  as  to  penetrate  be- 
tween it  and  the  pubes.  .  .  .  Upon  the  pubes  a  new  acetabulum  is 
formed    for  the  neck   of   the  thigh    bone,   the 
head  of  the  bone  being  above  the   level  of  the  Fig.  462. 

the  pubes  (Fig.  401).  .  .  .  The  femoral  artery 
and  vein  were  placed  on  its  inner  side, 
so  that  the  head  of  the  bone  rested  between  the 
crural  sheath  and  the  anterior  inferior  spinous 
process  of  the  ilium." 

Verneuil,^  in  attempting  to  make  reduction 
thirty-six  hours  after  the  accident  in  a  patient 
eighty-one  years  old,  fractured  the  neck  of 
the  femur.  Four  years  later  the  patient  died ; 
the  head  was  found  lying  in  the  notch  between 
the  anterior  inferior  spinous  process  and  the 
iliopectineal  eminence,  between  the  psoas  and 
the  rectus.  In  another  old  case  reported  by 
Douglas  ^  in  which  there  was  also  a  fracture  of 
the  neck  of  the  femur  the  head  was  on  the 
inner  side  of  the  vessels ;  the  history  of  the  case 
did  not  show  when  the  fracture  had  been  pro- 
duced. 

Symptoms.  The  cases  in  which  the  head  of 
the  femur  lies  upon  the  iliopectineal  eminence 
appear  to  be  the  more  common,  and  this  may, 
therefore,  be  taken  as  the  typical  form  ;  in  it 
the  limb  is  but  slightly,  if  at  all,  abducted, 
markedly  everted,  and  somewhat  shortened 
(Fig.  402),  and  the  head  of  the  femur  can  be 
I'elt  more  or  less  distinctly  in  the  groin,  with 
tlie  artery  pulsating  directly  in  front  of  it  or  to  fts  inner  side.  When 
the  head  is  displaced  further  toward  the  median  line  the  limb  is 
abducted  and  flexed  as  well  as  everted,  and  its  ]>osition  is  more  like 
that  of  an  ol)turator  dislocation  ;  the  ca])ital  diffei'ence  is  the  position 
of  the  head  on  the  pubis  where  it  can  be  distuictly  felt  and  perhaps 
even  .seen.  The  vessels  lie  on  its  outer  side.  In  both  forms  the  outer 
and  posterior  ])ortions  of  the  hip  are  flattened,  and  the  trochanter  can 
be  felt  covering  the  cavitv  of  the  acetabulum. 


Iliopectineal  dislocaiion. 
"  The  limb  is  usually  a  little 
more  advanced  and  abduct- 
ed."   (BiGEI.OW.) 


^  (.'oopcr  :  Loc.  cit.,  p.  78,  and  Ciuy's  Hospital  Kcjiorts,  1836,  vol.  i.  p.  82. 

2  Cooper:  Loc.  cit.,  p.  71. 

^  VeiMHuil:  Bull,  de  la  Socictc  dc  Chirurgic,  1H70,  vol.  xi.  p.  145. 

*  Douglas:  J^ondon  and  Ediuh.  Monthly  Journ.  ol"  .Med.  Sci.,  LS4.'5,  vol.  iii.  ji.  1()G4. 


844  DISLOCATIONS. 

Adduction  is  difficult  or  impossible ;  abduction  and  flexion  usually 
are  easv.  Some  patients  have  been  able  to  walk  immediately  after 
the  accident,  but  none  appear  to  have  done  so  as  freely  as  some  with 
obturatt)r  or  supposed  supracotyloid  dislocations. 

The  attitude  of  the  limb  is  like  that  found  after  fracture  of  the 
neck  of  the  femur,  and  the  differential  diagnosis  is  made  by  attention 
to  the  presence  of  the  head  in  the  groin,  the  flattening  of  the  outer 
aspect  of  the  hip,  and  the  depression  of  the  trochanter. 

In  a  case  reported  by  Rothe  ^  the  patient,  a  girl  fifteen  years  old, 
was  unable  to  extend  the  leg  upon  the  thigh  three  weeks  after  the  acci- 
dent, and  the  disability  was  attributed  to  overflexion  of  the  knee  at  the 
time  the  dislocation  was  received.  While  pushing  a  swing  forward 
she  tripped,  fell  on  her  knee,  and  was  then  pressed  backward  to  the 
ground  by  the  returning  swing.  Reduction  was  made  under  chloro- 
form by  flexion,  rotation  inward,  and  adduction. 

Of  the  intrapelvic  (Scriba)  or  suprapedinecd  (Bartels)  dislocation 
cases  have  been  reported  in  detail  by  Scriba,"  Bartels,'^  and  Stokes 
(above  quoted).  Scriba's  patient,  a  boy  thirteen  years  old,  while  stand- 
ing with  his  legs  wide  apart  and  the  left  one  thrown  back,  was  struck 
upon  the  breast  and  overthrown.  The  limb  was  flexed  at  the  knee  and 
hip,  adducted  and  rotated  inward.  The  head  of  the  femur  lay  above 
the  torn  Poupart's  ligament  deep  in  the  iliac  fossa,  and  the  neck  rested 
on  the  superior  ramus  of  the  pubis.  The  artery,  vein,  and  nerve 
crossed  the  head  and  were  fully  compressed.  Slight  inward  rotation 
and  adduction  were  the  only  movements  possible.  During  manipula- 
tion outward  rotation  suddenly  took  place  and  persisted.  Reduction 
was  made  by  lifting  the  head  with  the  fingers  until  it  rested  on  the 
ramus,  and  then  following  with  acute  flexion,  adduction,  inward  rota- 
tion, and  finally  extension. 

Bartels's  patient  was  a  man  forty-seven  years  old  who  had  been 
thrown  down  by  a  heavy  weight.  The  limb  was  shortened  about  three 
inches,  fully  extended,  parallel  to  the  median  line  of  the  body,  and 
widely  rotated  outward.  The  fold  of  the  groin  was  obliterated  by  a 
diffuse  swelling  extending  to  the  upper  limit  of  the  left  hypogastrium  ; 
the  head  could  be  distinctly  palpated  through  the  abdominal  wall, 
which  it  slightly  raised  ;  the  greater  trochanter  was  directed  backward 
and  could  not  be  felt.  Flexion  was  impossible  ;  inward  rotation  very 
limited. 

Treatment.  The  rule,  of  M'hich  the  application  is  so  general,  that  in 
attempting  reduction  the  limb  should  first  be  placed  in  the  position 
which  it  occupied  when  the  dislocation  occurred,  is  not  suitable  to 
those  suprapubic  dislocations  in  which  the  dislocation  takes  place 
while  the  limb  is  extended.  Traction  upon  the  fully  extended, 
abducted,  and  everted  limb  has  indeed  been  sometimes  successful,  but 
it  has  oftener  failed  and  has  led  to  various  accidents.  The  method 
was  early  abandoned  because  of  the  risk  of  injury  to  the  vessels  by 
overstretching  across  the  projecting  head  of  the  femur,  and  flexion  was 


1  Eothe:  Deutsche  Klinik,  1868,  p.  343. 

2  Scriba:  Centralblatt  fur  Chirurgie,  1879,  p.  703. 
'  Bartels  :  Arch,  fiir  klin.  Chir.,  vol.  xvi.  p.  651. 


DISLOCATIONS  OF  THE  HIP.  845 

resorted  to  to  diminisli  this  risk  iind  to  remove  what  was  thought  to  be 
the  principal  obstacle,  tension  of  the  psoas  and  iliacns.  Of  the  six 
procedures  given  by  Bigelow  almost  all  include  traction  upon  the 
flexed  thigh  and  rotation  inward  ;  in  some,  direct  pressure  downward 
and  outward  upon  the  head  of  the  bone  or  the  upper  part  of  the  thigh 
is  recommended,  and  outward  rotation  is  mentioned  in  one  as  an  equally 
good  substitute  for  inward  rotation. 

Kocher's  method  is  the  same  as  one  of  those  given  by  Bigelow,  and 
I  reproduce  it  here  because  of  its  more  detailed  account  of  the  obstacles 
to  be  overcome  and  the  means  by  which  the  manipulation  accom- 
plishes it. 

Flexion  relaxes  the  Y-ligament,  but  nevertheless  by  tightening  the 
posterior  part  of  the  capsule  it  presses  the  head  more  firmly  against 
the  brim  of  the  pelvis  or  even  pushes  it  further  upward  under  P<ju- 
part's  ligament ;  it  is  therefore  uecessary  that  the  movement  should 
not  be  allowed  to  take  place  upon  the  head  as  a  centre,  but  that  the 
head  should  be  enabled  or  forced  to  descend  along  the  anterior  surface 
of  the  pelvis  as  the  knee  is  raised  before  the  tightening  of  the  posterior 
portion  of  the  capsule  has  made  this  descent  impossible.  This  can  be 
effected  by  traction  in  the  axis  of  the  limb  or  by  direct  pressure  down- 
ward and  backward  upon  the  head.  The  steps  of  the  method,  then, 
are : 

1.  Traction  in  the  axis  of  the  limb  as  it  lies,  in  order  to  bring  the 
head  below  the  brim  of  the  pelvis ;  it  is  rarely  necessary  to  aid  this  by 
increasing  the  extension,  abduction,  and  outward  rotation  of  the  limb. 
By  this  means  the  posterior  portion  of  the  capsule  is  made  tense,  and 
its  point  of  attachment  to  the  back  of  the  neck  of  the  femur  is  thereby 
made  the  centre  for  the  following  movements : 

2.  Pressure  with  the  hand  upon  the  head  of  the  femur  to  prevent  its 
return  upward  during  flexion.  Sometimes  this  is  sufficient  to  make 
reduction. 

3.  Flexion,  in  order  to  relax  the  Y-ligament ;  it  should  not  be  car- 
ried to  a  right  angle,  otherwise  too  much  strain  will  be  made  upon  the 
posterior  portion  of  the  capsule. 

4.  Rotation  inward,  by  which  the  head  is  returned  to  the  socket. 
In  cases  in  Avhich  the  head  lies  nearer  the  symphysis  abduction  of 

the  liml)  during  traction  is  necessary  to  relax  the  Y-ligament  and  the 
untorn  portion  of  the  capsule  and  thus  allow  the  head  to  approach  the 
acetabulum  ;  and  in  those,  possibly  rare,  cases  in  which  this  ]>osition  is 
secondary  to  a  primary  displacement  downward  and  inward  (obturator) 
the  flexion  will  be  seen  to  bring  the  head  back  to  the  obturator  fora- 
men, and  then  the  final  steps  should  be  those  suitable  to  that  form  of 
dislocation. 

DISLOCATIONS  DIRECTLY  UPWARD. 

Subspinous  (Bigelow).     Supracotyloidea.     Sus-cotyloidienne 

(Malgaig-ne). 

Concerning  no  other  class  of  rci)ortc(l  cases  of  dislocations  of  the  hip 
is  the  uncertainty  as  to  the  nature  and  extent  of  the  lesion,  the  point 


846  DISLOCATIONS. 

at  which  the  head  has  left  the  socket,  and  the  mode  of  production  so 
great  as  in  those  in  which  the  head  is  found  more  or  less  directly  above 
the  socket.  As  has  been  above  said,  Blasius  grouped  under  one  head 
— supracotyloidea — cases  in  which  the  head  of  the  femur  comes  to  rest 
above  the  socket  either  by  secondary  displacement  forward  and  upward 
from  a  primary  dorsal  (the  everted  dorsal  of  the  jiresent  classification), 
or  by  secondary  displacement  backward  from  a  primary  suprapubic,  or 
by  direct  dislocation  upward,  and  this  grouping,  which,  while  very 
proper  in  a  monograph,  seems  to  me  objectionable  in  a  systematic 
description  of  all  the  forms,  has  been  accepted  and  followed  by  several 
of  the  later  German  writers,  Albert,  Konig,  Lessen.  Bigelow  groups 
Malgaigne's  variety  with  those  cases  in  which  the  head  lies  further  to 
the  inner  side  (suprapubic),  and  makes  them  all  a  subvariety  under 
the  name  subspinous.  Hamilton  makes  no  formal  classification  of 
them,  but  contents  himself  with  citing  a  few  cases,  mainly  as  "anom- 
alous dislocations, "  some  as  subspinous,  others  as  supraspinous. 

The  essential  feature  of  the  class,  as  I  view  it,  is  the  rupture  or 
avulsion  of  the  upper  part  of  the  Y-ligament;  this  diiferentiates  it 
radically  in  its  probable  mode  of  production  and  treatment  from  those 
in  which  the  head  of  the  bone  comes  to  rest  at  or  near  the  same  place 
after  having  left  the  socket  at  a  lower  point  in  front  or  behind  and 
passed  upward  on  either  side  of  the  untorn  ligament. 

The  incompleteness  of  many  of  the  descriptions  is  such  that  the 
material  for  a  positive  opinion  upon  the  character  of  the  displacement 
is  lacking,  and  such  cases  must,  therefore,  be  passed  by  without  defi- 
nite classification,  but  there  remain  a  few  which  sufficiently  establish 
the  existence  of  this  variety  in  which  the  head  is  displaced  directly 
upward  toward  or  a  little  behind  the  anterior  inferior  spinous  process 
of  tlie  ilium. 

The  cases  in  which  the  position  of  the  head  of  the  femur  has  been 
verified  b_y  autopsy  are  those  of  Wormald,^  Gerdy,^  Travers,'^  and  St. 
George's  Hospital,*  and  the  doubtful  ones  of  Cruveilhier,^  G4ly/ and 
Deville.'^  Wormald's  patient  was  a  man  forty  years  old,  who  had 
received  his  injury  at  the  age  of  fourteen,  and  had  since  had  good  use 
of  the  limb.  The  head  of  the  femur  lay  "  between  the  edge  of  the 
acetabulum  and  the  anterior  inferior  spinous  process,"  and  was  sur- 
rounded by  the  capsule.  The  ligamentura  teres  was  not  ruptured.  The 
cotyloid  cavity  formed  part  of  the  new  socket.  The  limb  was  some- 
what everted  and  abducted,  and  shortened  half  an  inch.  Gerdy's  patient 
was  caught  in  a  revolving  shaft  and  whirled  around  by  it  many  times. 
He  died  on  the  following  day.  The  head  of  the  femur  lay  on  the 
outer  third  of  the  upper  border  of  the  acetabulum,  below  and  just  out- 
side of  the  anterior  inferior  spinous  process  ;  the  capsule  was  torn  along 
the  upper  edge  of  the  cavity,  and  the  centre  of  the  head  was  eight  lines 

1  W^ormald  :  London  Medical  Gazette,  1837,  vol.  xix.  p.  658. 

2  Gerdy  :  Eeported  by  Baron.  Gaz.  Medicale  de  Paris,  1838,  p.  630. 

3  Travers  :  Medico-Ciiirurgical  Transactions,  1837,  vol.  xx.  p.  112.     Autopsy  by  Cadge  : 
Ibid.,  18.5,5,  vol.  xxxviii.  p.  88. 

♦  St.  George's  Hospital :  Lancet,  1840-41,  vol.  ii.  p.  281. 

s  Cruveilhier:  Bull,  de  la  Sec.  Anatomique,  1837,  p.  164. 

6  Gely  :  Ibid.,  1840,  p.  303.  '  Deville  :  Ibid.,  1843,  p.  264. 


DISLOCATIONS  OF  THE  HIP. 


847 


Fig.  4G3. 


above  that  of  the  latter.     Fig.  360  represents  an  apparently  similar 
specimen. 

In  Travers  and  Cadge's  case  the  head  lay  between  the  superior 
and  inferior  spinous  processes  of 
the  ilium  (Fig.  463)  and  was  cov- 
ered by  a  complete  bony  cap  lined 
with  a  dense  pearly-white  tissue 
resembling  fibro  -  cartilage.  The 
edge  of  the  new  cavity  was  con- 
nected with  the  neck  of  the  femur 
by  a  thick  capsular  ligament. 
The  rectus  muscle,  which  had 
been  torn  from  its  origin,  was  in- 
serted upon  the  edge  of  the  new 
cavity. 

The  St.  George's  Hospital  case 
was  a  recent  one ;  the  head  of  the 
femur  lay  about  an  inch  below  and 
to  the  outer  side  of  the  anterior 
spinous  process,  and  the  trochanter 
was  still  further  to  the  outer  side  and 
behind;  the  trochanter  minor  rested 
on  the  outer  edge  of  the  acetabulum. 
The  capsular  ligament  was  exten- 
sively lacerated  at  its  upper  part. 
The  gluteus  raedius  and  minimus 
were  nearly  torn  through  about  two 
inches  from  their  attachment  to  the  trochanter;  the  gemelli  and  quad- 
ratus  femoris  were  slightly  lacerated. 

The  following  case,  which  I  reported  in  the  Annals  of  Surgcn/,  De- 
cember, 1892,  shows  the  symptoms  (Fig.  464).  A  man  forty  years  old 
was  thrown  down  by  a  heavy  case  which  slipped  while  he  was  unload- 
ing it  from  a  wagon  and  forced  him  backward  against  another  box  and 
then  sidewise  to  the  ground.  When  I  saw  him,  three  hours  later,  he 
was  lying  on  his  back  with  the  right  thigh  extended,  slightly  abducted, 
and  so  far  everted  that  the  foot  rested  along  the  entire  length  of  its 
outer  border  on  the  bed.  The  upper  anterior  portion  of  the  thigh  close 
below  the  groin  was  rounded  and  swollen,  and  showed  two  incomplete 
transverse  rents  in  the  skin  about  two  inches  long  and  about  two  inches 
below  the  anterior  superior  spine  of  the  ilium,  which  evidently  had 
been  caused  by  overstretching  of  the  skin  (hyjierextension  of  the 
joint).  The  outward  rotation  gave  the  thigh  a  very  peculiar  a|)|)ear- 
ance ;  the  bulk  of  the  quadriceps  extensor  formed  a  longitudinal  mass 
on  the  outer  side  between  the  anterior  (inner)  aspect  and  a  deej)  longi- 
tudinal depression  extending  from  the  trochanter  to  the  side  of  the 
knee.  Every  attempt  to  move  the  limb  caused  pain  and  sliarj)  con- 
traction of  the  nuiscles. 

Ether  was   administered.     The  limb  could    then    be  easily   placed 


Old  supracotyloid  dislocation. 
and  Cadge's  case. 


Travers 


848 


DISLOCATIONS. 


alongside  of  and  parallel  with  the  other ;  the  shortening  was  two  cen- 
timetres. The  head  of  the  femur  lay  directly  beneath  the  skin  and 
could  be  distinctly  outlined.  It  lay  just  external  to  a  line  drawn 
downward  from  the  anterior  superior  spinous  process,  and  its  upper 
border  was  about  one  inch  below  that  prominence.  Internal  rotation 
was  impossible  ;  moderate  flexion  was  easy. 

Reduction  was  easily  effected  by  flexing  the  hip  about  twenty 
deo'rees,  and  then  making  moderate  traction  along  its  axis  with  one 
hand  at  the  knee,  and  direct  pressure  downward  and  backward  upon 
the  head  of  the  femur  with  the  other.  By  fully  extending  the  thigh 
and  making  slight  pressure  forward  against  the  upper  part  of  its  pos- 
terior aspect  the  dislocation  was  easily  reproduced,  and  was  then  again 
reduced  as  before. 

Fia.  46-i. 


Upward  dislocation  of  the  hip.     (From  a  photograph.) 


Through  what  was  apparently  an  extensive  gap  in  the  soft  parts 
beneath  the  skin  at  the  point  occupied  by  the  head  of  the  femur  before 
reduction  I  could  distinctly  feel  the  surface  of  the  ilium  and,  a  little 
in  front,  the  anterior  inferior  spinous  process. 

A  long  side  splint  was  applied,  and  the  patient  placed  in  bed. 

Convalescence  was  uneventful,  and  the  patient  was  discharged,  April 
15th,  thirty-six  days  after  the  accident.  May  24th  he  called  on  me; 
he  walked  without  a  cane,  and  complained  only  of  a  slight  feeling  of 
weakness  in  the  liml).  Hyperextension  of  the  hip  caused  no  pain; 
active  flexion  of  the  hip  was  restricted  one-half. 

I  know  of  no  case  exactly  like  it.  One  reported  by  Morgan^  resem- 
bles it  in  tlie  apparent  mode  of  production  and  the  attitude  of  the 
1  Morgan  :  Guy's  Hospital  Reports,  1636,  p.  79. 


DISLOCATIONS  OF  THE  HIP.  849 

limb,  but  the  head  of  the  bone  lay  below  and  to  the  inner  side  of  the 
anterior  superior  spine.  Possibly  Cheever's  ease,  quoted  in  Chapter 
LI.  among  compound  dislocations,  may  have  been  of  the  same  kind ; 
the  description  is  not  sufficiently  detailed  to  make  it  certain.  It  was 
evident  that  my  case  just  escaped  being  made  compound  by  rupture 
of  the  tense  skin.  In  Mason's  and  Allin's^  and  in  Tiffanv's,"  the 
attitude  was  similar  and  tlie  head  of  the  bone  could  be  felt  below  or 
below  and  to  the  inner  side  of  the  anterior  superior  spine.  Allin 
reported  his  case  as  a  suprapubic  dislocation ;  his  patient  received  the 
injury  by  stumbling  and  falling  forward  while  ascending  a  flight  of 
steps.  In  each  case  reduction  was  eifected  with  some  difficulty  by 
traction  and,  in  Allin's  and  Tiffany's,  rotation  inward.  Possibly  some 
of  the  "  intrapelvic "  dislocations  have  been  produced  in  the  sam<3 
manner,  and  differ  only  in  the  higher  position  of  the  head  given  by 
secondary  displacement. 

There  is  another  small  group  of  cases  in  which  the  displacement  is 
thought  to  be  of  th-j  same  kind  but  of  less  extent,  and  the  opinion 
finds  some  support  In  the  autopsy  of  Wormald's  case,  above  quoted. 
There  are  eversion,  slight  shortening,  and  some  flexion  of  the  limb, 
and  the  patients  have  usually  been  able  to  walk.  The  head  of  the 
femur  cannot  be  felt ;  the  trochanter  is  prominent,  slightly  elevated,  and 
more  distant  from  the  symphysis  pubis  than  its  fellow  is.  Milner's^ 
case  is  the  least  doubtful  example.  It  may  be  remembered  that  cases 
with  quite  similar  symptoms  have  been  reported  as  thyroid  disloca- 
tions. 

In  others,  with  the  same  attitude  of  the  limb,  the  head  of  the  femur 
could  be  felt  directly  above  the  socket  or  a  little  to  the  inner  side. 

In  the  first  group  it  is  evident  that  in  some  the  Y-ligament  and 
attachment  of  the  rectus  are  freely  ruptured,  and  that  in  others  the 
head  is  displaced  slightly  upward  and  the  upper  part  of  the  capsule 
only  partly  torn,  and  the  neck  of  the  femur  probably  crossed  by  the 
untorn  rectus,  a  condition  differing  only  slightly  from  the  suprapubic. 

In  the  second  group  it  is  possible  that  the  head  is  dis])laced  upward 
to  the  outer  side  of  the  inferior  spinous  process  where  it  would  be 
hidden  by  the  overlying  muscles,  but  in  that  case  the  marked  eversion 
noted  in  all  is  inexplicable  without  rupture  of  the  Y-ligament.  I  am 
disposed  to  think  the  cases  were  all  thyroid  dislocations,  an  o]>inion 
supported  by  the  slight  fulness  of  the  groin  and  elevation  of  the  fem- 
oral artery  noted  in  Milner's. 

DISLOCATION  DOWNWARD  UPON  THE  TUBEROSITY  OF  THE 
ISCHIUM.     INFRACOTYLOID. 

In  this  form  of  dislocation  the  head  escapes  over  the  lower  edge  of 
the  socket  and  rests  just  below  it  upon  the  outer  surface  of  the  body 
of  the  ischium.     Tlie  reported  cases  are  very  few,^  but  it  seems  prob- 

'  Alliu  :  Eeported  by  Jlaiiiiltou,  loc.  cit.,  p.  785. 

2  Tiffauy  :  Maryland  Medical  Journal,  1883,  vol.  x.  p.  o25. 

■'  Milner :  St.  Bartholomew's  Hospital  Kciiorts,  1H74,  vol.  x.  p.  31fi. 

■*  For  bibliography  and  ca.ses  sec  :  (  liaiijilain,  Hull,  de  la  Hoc.  de  Cliir.,  1874,  p.  401  ;  Wen- 
del,  Deutsche  Zeitschrift  fiir  Chir.,  1!)04,  \ul.  Ixxii.  p.  153,  and  Nii-.'erle,  Ontralblatt  fur 
Chir.,  1905,  p.  31  (20  cases). 


850  DISLOCA  TIOXS. 

able  that  the  dislocation  is  much  more  frequent  as  a  primary,  transi- 
tory one,  leading  to  either  a  dorsal  or  an  obturator  dislocation,  being 
converted  into  the  former  by  inward  rotation  and  adduction,  or  into 
the  latter  by  outward  rotation  and  abduction  ;  and,  furthermore,  some 
of  the  cases  have  probably  been  reported  as  obturator  dislocations,  for 
the  dividing  line  between  them  is  somewhat  arbitrary  ;  thus,  Keate's 
case,  referred  to  above  in  the  paragraph  on  the  causes  of  obturator 
dislocations,  is  quoted  by  Malgaigne  as  a  subcotyloid  dislocation.  The 
form  was  first  described  by  Bonn  ^  in  1800,  and  again  by  Ollivier.^ 

The  cause  is  the  same  as  that  of  many  dorsal  and  obturator  disloca- 
tions, namely,  forcible  flexion  of  the  thigh,  but  exaggerated  abduction 
followed  by  slighter  flexion  appears  also  to  be  capable  of  producing  it. 
Thus,  in  a  case  reported  by  Roux^  the  patient  fell  with  his  right  leg  in 
a  hole ;  the  left  one  remained  stretched  out  on  the  ground  in  abduction 
and  was  dislocated ;  and  Ollivier's  patient,  a  man,  seventy-two  years 
old,  was  knocked  down  by  a  branch  of  a  falling  tree  which  struck 
against  the  lower  inner  part  of  his  right  thigh  and  forcibly  abducted  it. 
Pitha^  speaks  of  a  case  in  which  the  dislocation  was  caused  by  the 
forcible  bending  of  the  body  backward,  but,  as  Albert  points  out,  not 
only  is  his  description  of  the  symptoms  unintelligible,  but  it  also  does 
not  appear  how  a  rent  in  the  lower  part  of  the  capsule  could  be  pro- 
duced in  this  way.  He  describes  the  supracotyloid  and  infracotyloid 
together  as  "  vertical  dislocations,"  and  possibly  has  placed  this  case 
in  the  wrong  paragraph. 

The  only  autopsy  is  one  reported  by  Luke,^  the  patient,  a  man,  fifty 
years  old,  died  in  consequence  of  associated  injuries;  the  dislocation, 
which  had  been  easily  reduced,  was  reproduced  at  the  autopsy,  and  as 
the  bone  could  be  made  to  take  no  other  position  it  was  thought  that 
tlie  reproduction  was  exact.  The  head  of  the  femur  was  situated 
"midway  between  the  ischial  notch  and  the  thyroid  hole,  immediately 
beneath  the  lower  border  of  the  acetabulum ; "  the  gemellus  inferior 
and  quadratus  femoris  had  been  torn,  and  the  ligamentum  teres  com- 
pletely detached ;  the  capsule  was  torn  in  its  lower  part. 

Experiment  upon  the  cadaver  shows  that  the  Y-ligament  remains 
untorn  and  compels  flexion  of  the  thigh  upon  the  pelvis,  which,  how- 
ever, may  be  masked,  as  in  other  forms,  by  inclination  of  the  pelvis. 
The  retention  of  the  head  upon  the  tuberosity  is  due  to  the  narrowness 
of  the  rent  in  the  capsule  and  to  the  support  given  by  the  untorn  por- 
tions;  and  as  the  laceration  can  be  easily  extended  on  either  side  the 
easy  transformation  into  a  dorsal  or  obturator  dislocation  is  intelligible. 

The  flexion  may  be  even  to  a  right  angle ;  Ollivier's  patient  was 
brought  to  the  hospital  seated  in  a  chair ;  the  limb  is  more  or  less 
abducted,  and  may  be  slightly  inverted  or  everted.  Measurement  in 
Ollivier's  case,  when  the  other  thigh  was  brought  into  a  similar  posi- 
tion, showed  no  difference  in  length,  and  by  the  lengthening  which  has 
been  noted  in  other  cases  was  probably  meant  only  an  apparent  elon- 

1  Bonn  :  Quoted  by  Lossen. 

2  Ollivier :  Arch.  gen.  de  Med.,  1823,  vol.  iii.  p.  505. 

^  Eoux  :  Revue  Medico-chirurgicale,  1849,  vol.  v.  p.  364. 

♦  Pitha :  Pitha  and  Billroth,  y>.  163. 

*  Luke:  Medical  Times  and  Gazette,  1858,  vol.  1.  p.  12. 


DISLOCATIONS  OF  THE  HIP.  851 

gation  due  to  the  abduction  and  the  consequent  inclination  of  the  pelvis. 
The  buttock  appears  rounded  and  more  prominent,  especially  M'hen 
looked  at  from  below  when  the  patient  is  lying  on  his  back  with  both 
thighs  flexed,  and  the  adductors  of  the  thigh  are  tense  and  prominent. 
The  great  trochanter  is  further  from  the  crest  of  the  ilium,  and  the 
head  of  the  femur  can  sometimes,  but  rarely,  be  felt  in  its  new  position. 

Movements  of  the  limb  are  restricted  and  more  or  less  painful ; 
flexion  to  a  right  angle  is  usually  possible,  abduction  comparatively 
free,  adduction  limited  ;  but  in  Roux's  case  the  thigh  could  be  carried 
across  the  other  one.  Both  of  Gurney's^  patients  could  walk  fairly 
well  immediately  after  the  accident,  and  Roux's  could  walk  a  little  at 
first,  but  Mas  soon  completely  disabled  by  the  pain. 

Reduction  has  been  easy  (Roux  was  unsuccessful  on  the  thirty-fifth 
day  with  the  aid  of  chloroform)  and  has  usually  been  effected  by  trac- 
tion in  the  axis  of  the  limb,  with  or  without  direct  pressure  upon  the 
head  of  the  bone  ;  sometimes  the  dislocation  has  been  first  transformed 
into  a  dorsal  or  obturator  and  then  reduced. 

A  suitable  method  would  be  :  Flexion,  if  not  already  present ;  trac- 
tion ;  correction  of  the  existing  rotation,  if  any  ;  to  be  aided  by  direct 
pressure  on  the  head  of  the  femur  from  behind. 

Dislocation  into  the  pelvis  through  the  fractured  floor  of  the  acetab- 
ulum, sometimes  termed  central  dislocation,  has  been  described  in 
Chapter  XXII.  A  brief  reference  is  made  by  Kronlein-  to  a  unique 
case  observed  by  him  in  which,  by  a  fall  upon  the  feet,  the  head  of 
each  femur  was  driven  through  the  floor  of  the  acetabulum. 

1  Gurney:  Lancet,  1845,  vol.  iii,  p.  412. 

2  Kronlein:  Deutsche  Chirurgie,  Lief.  26,  p.  25. 


CHAPTER   LIIL 

DISLOCATIONS  OF  THE  HIP.— (Continued.) 

Complications — Simultaneous  Dislocation  of  Both  Hips — Accidents  in  Attempts 
to  Reduce — Prognosis — Habitual  Dislocations — Treatment  of  Old  Disloca- 
tions— Congenital  and  Pathological  Dislocations. 

COMPLICATIONS    OF    DISLOCATIONS    OF    THE   HIP. 

Among  the  complications  of  dislocations  of  the  hip  are  unusually 
extensive  injuries  to  the  soft  parts,  rupture  of  or  dangerous  pressure 
upon  large  nerves  and  blood-vessels,  and  fracture  of  bones.  Mention 
has  been  made  of  all  in  connection  with  the  different  varieties  of 
dislocation,  and  it  is  necessary  only  to  group  and  briefly  summarize 
them. 

Rupture  or  laceration  of  the  muscles  about  the  joint  is  doubtless 
present  in  some  degree  in  all  cases,  and  is  rarely  so  extensive  as  to 
deserve  to  be  looked  upon  as  a  complication.  In  the  dorsal  disloca- 
tions the  head  of  the  femur  may  be  so  far  displaced  that  the  gluteus 
medius,  and  even  the  gluteus  maximus  may  be  in  part  ruptured,  and 
in  the  thyroid  dislocations  the  adductors  may  be  extensively  torn  from 
the  inferior  ramus  of  the  pubis  and  the  adjoining  part  of  the  ischium, 
as  observed  in  Taylor's  compound  case  above  quoted.  In  the  supra- 
pubic form  the  pectineus  may  be  torn,  and  in  the  extreme  variety 
known  as  "  intrapelvic,"  in  which  Poupart's  ligament  is  ruptured,  the 
attached  muscles  forming  the  anterior  wall  of  the  abdomen  must  also 
suffer  some  injury.  The  extension  of  the  bruising  and  laceration  of 
course  increases  the  shock  and  inflammatory  reaction,  but  calls  for  no 
special  treatment  beyond  a  more  rigid  and  prolonged  confinement  to 
bed  and  avoidance  of  movement. 

For  compound  dislocations  see  Chapter  LI. 

Rupture  or  injury  of  the  femoral  vessels  has  been  observed  only  in 
suprapubic  and  obturator  dislocations.  The  suprapubic  ones  are  those 
of  a  German  military  surgeon^  and  Goldsmith,^  quoted  in  Chapters 
XXIX.  and  LI. ;  the  obturator  case  is  that  of  Duboue.^  In  the  first 
mentioned  the  femoral  vein  was  torn  and  the  patient  died  promptly ; 
in  Goldsmith's  an  aneurism  involving  the  external  iliac  and  femoral 
arteries  formed,  and  was  treated  two  months  after  the  accident  by  liga- 
ture of  the  external  iliac ;  the  patient  died.  In  Duboue's  case  there 
was  also  fracture  of  the  pelvis  at  the  junction  of  the  ilium  and  pubis, 
but  without  displacement ;  the  head  of  the  femur  rested  upon  the 
ischio-pubic  branch  of  the  pelvis  rather  below  than  upon  the  obturator 
externus ;  the  femoral  vein  was  torn.     The  patient  died. 

'  Centralblatt  fiir  Chirurgie,  1880,  p.  504. 

^  (roldsmith:  American  Journal  of  the  Medical  Sciences,  July,  1860,  p.  30. 

3  Duboue  :  Bull,  de  la  Soc.  Anatomique,  1858,  p.  496. 

(852) 


DISLOCATIONS  OF  THE  HIP.  853 

The  sciatic  nerve  in  the  autopsy  of  cue  dorsal  dislocation^  has  been 
found  stretched  across  the  front  of  the  neck  of  the  femur,  and  in  sev- 
eral dislocations  produced  experimentally  upon  the  cadaver  it  has  been 
found  in  the  same  position,  but  the  only  recorded  instances  within  my 
knowledge  in  which  symptoms  of  injury  to  it  have  been  present  are  a 
case  reported  by  Jonathan  Hutchinson"  in  which  the  muscles  supplied 
by  it  were  paralyzed  and  remained  so  at  the  time  of  the  report  several 
months  after  the  accident,  and  one  by  Allis  {The  Hip)  in  which  the 
attempts  to  reduce  were  thought  to  have  wound  the  nerve  about  the 
neck  of  the  femur. 

Associated  fractures  of  the  head,  neck,  and  shaft  of  the  femur,  of 
the  rim  and  floor  of  the  acetabulum,  and  of  different  parts  of  the 
pelvis  have  been  reported. 

Fracture  of  the  head  of  the  femur  has  been  reported  in  four  cases  of 
dorsal  dislocation.^ 

Fracture  of  the  neck  of  the  femur  occurring  coincidently  with  the 
dislocation  or  subsequently  during  an  attempt  to  reduce  has  been 
observed  a  number  of  times.  Wippermann*  reported  one  case  and 
collected  thirteen  others  of  which  he  gives  abstracts,  but  his  list 
includes  one  case  [Hervez  de  Chegoire)  which  was  probably  a  simple 
fracture  without  dislocation,  and  Birkett's,  in  which  the  fracture  was 
of  the  head,  and  does  not  include  a  number  of  other  reported  cases; 
thus,  Hamilton  quotes  no  less  than  twelve  cases  in  Avhich  fracture  was 
caused  during  an  attempt  to  reduce,  and  of  these  Wippermann's  paper 
contains  only  one. 

Monks  ^  reports  a  personal  case  and  quotes  several  reported  since  the 
publication  of  Wipi)ermann's  paper.  The  reported  cases  need  careful 
study,  for  in  several  of  them  the  diagnosis  is  wholly  untrustworthy.  In 
only  a  very  few — Tunecliffe,^  Post,^  Lossen,^  Schwartz,'^  Monks,  and 
possibly  Douglass  and  Hoefterman  '" — does  the  fracture  appear  to  have 
been  caused  at  the  same  time  as  the  dislocation.  In  the  others  it  was 
evidently  or  probably  caused  by  an  attempt  to  reduce.  In  the  three 
first  named  and  Hoefterman's  the  dislocation  was  dorsal,  in  Schwartz's 
thyroid,  and  in  Monks's  and  Douglass's  "  pubic."  TunecliflPe  first  saw 
his  patient  a  month  after  the  accident ;  he  made  reduction  and  the 
patient  "  progressed  favorably."  Lossen  first  saw  his  patient  six  weeks 
after  the  accident  and  did  nothing.  Post  first  saw  his  patient  (thirteen 
years  old)  six  months  after  the  accident ;  the  head  had  become  necrotic, 
with  a  sinus,  and  was  removed  ;  recovery  with  four  and  a  half  inches 
of  shortening.  Schwartz  made  reduction  by  first  transforming  the 
dislocation  into  a  dorsal  one  and  then  making  traction  with  the  hip  in 

1  Quain  :  Medico-Chirurgical  Transactions,  184S,  vol.  xxxi.  p.  337. 
^  Hutchinson  :  Medical  Times  and  (iazctte,  1866,  vol.  i.  ji.  101. 

*  Birkett,  Medico-Chinirgical  Transactions,  1869,  p.  133;  Moxon,  Medical  Times  and 
Gazette,  1872,  vol.  i.  p.  96  ;  Riedel,  Beilage  znm  Centralhl.  fiir  Cliir.,  188.",,  p.  92  ;  Crile, 
Annals  of  Surgerj',  May,  1891. 

*  Wippermann  :  Arcii.  fiir  klin.  Chinirgie,  vol.  xxxii.  p.  440. 
6  Monks:   Annals  f)f  Surgery,  1911,  vol.  liv.  p.  .393. 

6  Tunnecliff :  American  .Journal  of  the  Medical  Sciences,  1868,  vol.  Ivi.  p.  123. 

'  I'ost:  New  York  Medical  Record,  1878,  vol.  xiii.  p.  366. 

**  Lossen:  Deutsche  (Ihirurgie,  Lief.  6;"),  p.  55. 

9  Schwartz  :  Rev.  gen.  de  Chir.  et  Ther.,  1897,  xi.,  p.  809. 

^0  Hoefterman  :   Deutsche  Med.  Wochen.schft,  1904,  xxx.  p.  335. 


854  DISL  0  CA  TIONS. 

rectangular  flexion ;  the  next  day  the  signs  of  fracture  of  the  neck 
Avere  clear ;  good  recovery.  Monks  reduced  by  direct  pressure  upon 
the  head  ;  the  patient  died  an  hour  later.  Douglass  found  his  case  on 
the  autopsy  table  twelve  years  after  the  accident ;  the  head  rested  on 
the  ilio-pectineal  eminence  on  the  inner  side  of  the  artery  and  vein  ; 
the  broken  end  of  the  femur  had  dropped  back  and  was  fixed  to  the 
edge  of  the  acetabulum  by  fibrous  tissue,  allowing  some  movement. 
Wippermann  reduced  after  ten  weeks. 

The  cases  in  which  the  neck  has  been  broken  in  an  attempt  to  reduce 
the  dislocation  may  also  be  used  in  determining  the  prognosis  and  the 
method  of  treatment.  In  the  three  supra-pubic  cases  (Flower,  Douglass, 
Monks)  reduction  was  efPected  in  one  by  direct  pressure,  the  patient 
being  moribund  ;  in  one  the  head  was  excised  ;  in  one  nothing  was 
done  and'  nothing  is  said  of  the  usefulness  of  the  limb.  In  all  the 
fracture  was  of  the  narrow  part  of  the  neck.  Certainly  in  such  cases 
the  head,  if  irreducible  and  if  making  dangerous  pressure  on  the  vessels, 
should  be  excised.  And  even  if  it  can  be  reduced  it  is  probable  that 
the  periosteum  is  so  widely  torn  that  union  cannot  take  place.  It  is  to 
be  noted  that  in  three  cases  the  head  became  necrotic. 

The  successful  reduction  in  several  of  the  dorsal  cases  after  the  lapse 
of  a  considerable  interval — six  months  in  one — is  remarkable.  In 
fresh  cases  in  which  the  head  does  not  move  with  the  shaft  reduction 
by  manipulation  is  clearly  not  to  be  expected ;  whether  direct  pressure 
upon  the  head,  with  or  without  a  posterior  incision,  would  be  successful 
cannot  be  foretold,  but  it  seems  not  unlikely ;  and  in  fracture  through 
the  narrow  part  of  the  neck  the  loss  of  the  vascular  supply  of  the 
head  will  probably  be  complete,  and  even  if  reduction  should  be  made 
reunion  would  probably  fail.  Expectation  with  the  limb  in  a  selected 
position  or  excision  would  be  the  choice.  In  Schwartz's  case  (thyroid, 
transformed  into  dorsal,  reduced)  the  fracture  was  probably  at  the  base 
of  the  neck  without  separation  and  with  maintenance  of  much  of  the 
periosteal  and  ligamentary  connections. 

Fracture  of  the  shaft  of  the  femur,  occurring  coincidently  with  its 
dislocation,  has  been  observed  a  few  times.  Hamilton  collected  four 
cases,  those  of  Bloxham,  1833,  Thornhill,  1836,  Et^ve,  1838,  and 
Markoe,  1853,  in  all  of  which  it  is  claimed  that  reduction  was  effected. 
He  rejects  Thornhill's  claim  as  "  altogether  incredible,"  and  doubts 
if  a  dislocation  existed  in  Markoe's.  In  Bloxham's  and  Eteve's  the 
fracture  was  near  the  middle  of  the  shaft,  in  Thornhill's  in  its  upper 
third,  and  in  Markoe's  the  site  is  not  mentioned.  In  Bloxham's  the 
dislocation  was  on  the  pubis,  and  was  reduced  on  the  seventh  or  eighth 
day  by  traction  with  pulleys,  the  limb  having  been  secured  with  splints, 
and  by  direct  pressure  on  the  head  of  the  bone.  In  Eteve's  the  dis- 
location was  backward,  and  reduction  Avas  efPected  by  making  slight 
traction  upon  the  upper  part  of  the  flexed  thigh,  and  by  direct  pressure 
on  the  head  of  the  bone. 

To  these  may  be  added  Cooke's  case  of  obturator  dislocation  with 
fracture  just  below  the  trochanter,  quoted  in  C^hapter  IjIL,  Cooper's 
of  dorsal  dislocation  with  fracture  at  tlie  middle  of  the  shaft,  and 
Delagarde's  of  backward  dislocation  with  double  fracture  of  the  shaft. 


DISLOCATIONS  OF  THE  HIP.  855 

Cooke's  patient  was  nine  years  old,  and  rednction  was  easily  effected 
by  direct  pressure  on  the  head.  Cooper's^  patient  Mas  a  lad  sixteen  or 
eighteen  years  old  ;  "  as  the  reduction  of  the  hip  was,  of  course,  im- 
practicable," union  of  the  fracture  was  alone  sought  at  first,  and  after 
five  weeks,  the  bone  appearing  tolerably  firm,  careful  extension  by 
pulleys  was  made  for  half  an  hour,  and  was  successful.  He  also 
quotes  ^  another  case  in  which  reduction  was  not  made. 

In  Delagarde's^  case  the  dislocation  was  backward,  and  the  shaft  Mas 
broken  in  two  places.  The  dislocation  remained  unreduced,  and  the 
head  was  subsequently  excised. 

Kammerer^  reported  a  suprapubic  case  with  fracture  between  the 
upper  and  middle  thirds  in  whicii  reduction  was  not  made,  and  collected 
twelve  other  cases  of  fracture  of  the  shaft  with  various  dislocations. 

Possibly  reduction  might  be  effected  in  dorsal  cases  by  using  the 
weight  of  the  limb  to  make  traction  in  the  prone  position,  as  described 
in  Chapter  LI.,  and  in  other  forms  traction,  with  pressure  on  the  head, 
should  be  tried ;  this  failing,  McBurney's  hook  (Fig.  405)  should  cer- 
tainly be  tried,  as  it  involves  less  laceration  and  gives  better  control 
than  forceps  through  an  incision. 

Associated  fracture  of  the  pelvis,  usually  of  the  rami  of  the  pubis  and  is- 
chium,andsometimesextendingintotheacetabulum,  has  been  reported.  It 
has  always  been  caused  by  great  violence  acting  directly  upon  the  patient, 
and  has  usually  been  combined  M'ith  other  injuries  wiiich  have  proved  fatal. 

Fractures  of  the  acetabulum  have  been  mentioned  above  in  connection 
with  the  different  forms.     (See  also  Chapter  XXII.,  pp.  352,  358.) 

Detachment  of  the  Lahrum  Cartilagineum.  Zinner'^  reports  a  case  of 
dorsal  dislocation  complicated  by  a  double  vertical  fracture  of  the 
pelvis  extending  from  the  pectineal  eminence  through  the  margin  of 
the  acetabulum  to  the  tuber  ischii  and  through  the  inner  border  of  the 
inferior  ramus  of  the  pubis,  and  by  detachment  of  the  labrum  carti- 
lagineum ;  the  latter  was  entirely  torn  away,  with  the  exception  of  a 
small  piece  at  its  upper  outer  part,  and,  with  its  ends  tM'isted  about 
each  other,  Mas  M^edged  between  the  outer  margin  of  the  acetabulum 
and  the  neck  of  the  fenuir  and  prevented  reduction.  The  ligamentum 
teres  was  torn  from  the  acetabulum  and  remained  attached  to  the  head 
of  the  femur  and  to  the  labrum.  Detachment  of  a  portion  is  prob- 
ably not  rare. 

SIMULTANEOUS  DISLOCATION  OF  BOTH  HIPS. 

Simultaneous  dislocation  of  both  hips  has  been  reported  in  about 
thirty  cases."  Usually  the  dislocation  is  not  the  same  on  both  sides, 
but  if  backward  upon  the  ilium  in  one  it  is  forward  uj)on  the  obtura- 

1  Cooper:  Dislocations  and  Fractiiics,  American  edition,  18-14,  p.  40. 

*  Cooper :  Loc.  cit.,  p.  41. 

'  Delagarde:  St.  Bartholomew's  llosjatal  Reports,  1866.  vol.  ii.p.  183. 

*  Karameror  :  New  York  Medical  .Tournal,  February  16,  1889. 

5  Zinner:  Zeitschrift  fur  Heilkunde,  vol.  viii.  p.  121 ;  abstract  in  Centralblatt  furChir., 
18HH.  p.  .".. 

"  For  biljliojrraphy  of  26  cases  see  Niebans,  Dentsebe  Zeitschrift  fiir  Chirnrjric,  1H88, 
vol.  xxvii.  p.  467;  also  a  doiibb;  dorsal  dislocation,  Pfeiller,  in  Boston  Medical  and  Snrjri- 
cal  .Tonrnal,  Anjiust4,  1887,  and  Lewis,  Annals  of  Sintrery,  )i)04.  vol.  .\1  i>.  7:3."),  with  bib- 
liogiaphy  to  date.  Tschniarke,  Monatschrift  fur  rnralllieilkuM.ie,  l!)!)."),  No.  7.  reports  a 
case  and* collects  six  otlicrs  later  than  Niehans. 
■59 


856  '  DISLOCATIONS. 

tor  foramen  or  upon  the  pubis  in  the  other.  The  common  cause  is  a 
heavy  blow  received  upon  the  back  or  side  while  the  patient  is  bending 
forward,  by  M^hich  he  is  twisted  to  one  side,  so  that  one  thigh  is  abducted 
and  the  other  adducted.  Of  this  mode  of  production  Boisnot's  ^  case 
is  a  good  example  :  a  bale  of  goods  fell  upon  a  powerful  man,  forty 
years  old,  striking  him  upon  the  left  side  of  the  head  and  neck,  and 
bending  him  to  the  right,  and  caused  a  dorsal  dislocation  on  the  left 
side,  and  a  suprapubic  one  on  the  right.  In  Barker's  case,  quoted  in 
Chapter  LIT.,  both  dislocations  were  obturator,  and  were  caused  by  a 
fall  from  a  lieight  of  about  thirty  feet  upon  a  sand  bank,  the  patient 
striking  upon  his  feet  and  having  them  widely  separated.  In  Schin- 
zinger's  ^  case,  dorsal  on  one  side  and  suprapubic  on  the  other,  it  was 
thought  the  latter  might  have  been  caused  by  the  efforts  of  the  by- 
standers to  drag  the  patient  from  under  the  bank  of  earth  that  had 
fallen  upon  him. 

Simultaneous  dislocations  of  the  left  hip  backward  and  of  the  right 
knee  forward  and  upward  were  reported  by  Brittain/  and  of  the  hnee 
and  hip  of  the  same  side  by  Hulke.* 

ACCIDENTS  CAUSED  BY  ATTEMPTS  TO  REDUCE. 

Before  the  use  of  ether  and  chloroform  to  obtain  anaesthesia,  and 
the  general  substitution  of  milder  methods  in  the  place  of  forcible 
traction  by  pulleys,  it  was  not  rare  for  severe  inflammatory  reaction, 
and  even  suppuration,  to  follow  reduction  or  the  attempt  to  reduce,  or 
for  the  patient  to  die  in  consequence  of  the  shock  and  exhaustion  pro- 
duced by  the  efforts  of  the  surgeon.  Cooper^  says  "there  are  plenty 
of  cases  on  record  of  fatal  abscesses  from  violent  attempts  at  the 
reduction  of  dislocated  hips."  Such  consequences  are  now  extremely 
rare,  but,  even  when  forcible  traction  or  other  violent  manipulations 
have  not  been  employed,  they  must  still  be  expected  occasionally  to 
occur  as  the  result  in  part  at  least  of  the  original  traumatism. 

Fracture  of  the  neck  or  even  of  the  shaft  of  the  femur  has  been 
caused  in  a  number  of  cases  by  the  surgeon  in  his  efforts  to  reduce, 
either  by  forcible  traction  or  by  manipulation.  Although  in  modern 
methods  but  little  force,  comparatively,  is  applied  by  the  surgeon,  yet 
it  must  be  remembered  that  the  force  is  habitually  applied  on  the  long 
arm  of  a  lever  of  which  the  neck  of  the  femur  is  the  short  arm,  and 
the  fracturing  strain  upon  the  latter  is  thereby  greatly  augmented. 
The  fracture,  apparently,  takes  place  more  frequently  during  rotation 
or  abduction  than  during  the  flexion  of  the  limb.  In  most  of  the 
reported  cases  the  account  is  limited  to  the  circumstances  attending 
the  fracture,  and  no  mention  is  made  of  the  subsequent  course  of  the 
case.  Of  the  14  cases  collected  by  Wippermann  (^vide  supra),  includ- 
ing also  the  one  in  which  the  fracture  occurred  simutaneously  with 
the  dislocation  and  another  in  which  it  probably  did,  the  final  result  is 

1  Boisnot:  American  Journal  of  the  Medical  Sciences,  October,  1867,  p.  396. 
^  Schinziiiger :  Wiener  med.  Presse,  1880,  quoted  by  Kronlein. 
3  Brittain  :  London  Medical  Gazette,  1836,  vol.  xviii.  p.  257. 

*  Hulke :  British  Medical  Journal,  1883,  vol.  ii.  p.  1. 

*  Cooper  :  Loc.  cit.,  p.  33. 


DISLOCATIONS   OF  THE  HIP.  857 

indicated  in  9 ;  of  these  consolidation  of  the  fracture  took  place 
in  3  and  failed  in  6,  and  in  two  of  the  latter  (Czerny,  Bryck),  in 
both  of  which  the  fracture  was  secondary  and  through  the  narrow 
part  of  the  neck,  an  abscess  formed,  from  which  the  necrotic  head 
of  the  femur  was  subsequently  removed.  (See  also  Kammerer  and 
Monks,  supra.) 

Fractures  produced  during  moderate  manipulation  in  recent  cases 
should  be  treated  in  accordance  with  the  considerations  affecting  the 
treatment  of  simultaneous  fracture  and  dislocation. 

In  Stokes's  fatal  case  of  suprapubic  dislocation,  in  which  death  was 
attributed  to  pulmonary  embolus,  it  is  impossible  to  say  whetiier  the 
fatal  result  was  due  to  the  traumatism  or  to  the  reduction.  If  it  was 
due  to  pulmonary  embolus  the  clot  must  have  formed  before  reduction 
was  attempted,  and  the  latter  could  have  caused  only  its  detachment. 


PROGNOSIS    AND    AFTER-TREATMENT. 

The  prognosis  after  reduction  in  uncomplicated  cases  is  favorable, 
the  patients  usually  regaining  good  use  of  the  limb.  The  inflamma- 
tory reaction  is  usually  slight;  and  other  treatment  than  rest  in  bed 
for  two  or  three  weeks  is  rarely  required.  Occasionally,  there  is  a 
tendency  to  recurrence  wliich  needs  to  be  combated  either  by  slight 
permanent  traction  upon  the  limb  or  by  keeping  it  in  an  attitude  that 
is  unfavorable  to  recurrence  :  extension,  abduction,  and  outward  rota- 
tion after  a  dorsal  dislocation.  Sometimes  the  joint  remains  sensitive 
or  its  range  of  motion  is  restricted,  presumably  because  of  an  arthritis 
set  up  by  the  trauma,  especially  if  a  portion  of  the  rim  of  the  acetabu- 
lum has  been  broken. 

If  reduction  is  not  made  the  patient  will  be  permanently  crippled 
to  a  greater  or  less  degree.  Usually  a  new  articular  socket  is  formed 
by  bony  outgrowths  about  the  head  which  permits  some  motion,  and 
the  principal  disability  is  due  to  the  attitude  of  the  limb,  to  its  lack 
of  parallelism  with  the  other,  and  to  the  necessity  of  tilting  the  pelvis 
and  curving  the  spine  in  order  to  bring  the  foot  to  the  ground  ;  but  in 
a  few  cases  patients  have  also  suffered  from  persistent  pain  aggravated 
l)y  use,  and  even  from  numbness  or  paralysis  due  to  pressure  on  a  nerve. 

In  the  dorsal  dislocations  the  attitude  of  the  limb,  flexion  and  a1)duc- 
tion,  adds  considerably  to  the  actual  shortening,  and  the  patient  may 
be  unable  to  walk  without  crutches  or  a  support  attached  to  the  sole 
of  the  shoe.  In  unreduced  suprapubic,  supracotyloid,  and  obturator 
dislocations  the  attitude  is  often  less  faulty  and  in  a  number  of  cases 
the  limb  has  been  very  serviceable. 

HABITUAL    DISLOCATIONS. 

A  considerable  number  of  cases  have  been  reported  in  which  the 
hip  could  be  voluntarily  dislocated  by  muscular  ct)ntracti()n  or  by 
slight  pressure  upon  the  foot  wlicn  the  limb  was  j)laced  in  a  certain 
attitude,  or  in  which  the  dislocatio-n  recurred   invohintarily  (hiring  use 


858  DISL  0  CA  TIONS. 

of  the  limb.  Perier^  collected  fifteen  cases,  more  or  less  authentic, 
including  one  observed  by  himself  and  exhibited  to  the  Societe  de 
Ohirurgie,  and  Hamilton  nine  additional  ones.  In  some  the  peculi- 
arity clearly  followed  a  traumatic  dislocation,  in  others  it  was  the  con- 
sequence of  congenital  or  acquired  alterations  in  the  constituent  parts 
of  the  joint.  Only  the  former  will  be  here  considered,  the  latter 
belonging  more  strictly  in  the  classes  of  spontaneous  or  pathological 
dislocations. 

The  two  most  satisfactory  examples  are  one  observed  by  Bigelow^ 
and  another  quoted  by  him  from  a  report  furnished  by  Dr.  E.  M. 
Moore  ;  both  were  dorsal.  In  Bigelow's  case  '"  the  hip  was  dislocated 
while  the  legs  were  crossed,  a  wagon  in  which  the  man  was  riding 
having  pitched  into  a  hole.  In  a  few  hours  the  hip  was  reduced  by 
flexion.  Eight  days  after  the  accident,  in  attempting  to  walk  upon 
the  limb,  it  was  again  partially  luxated,  when  the  patient  himself 
replaced  it  by  pushing  against  it  with  one  hand  and  pressing  with  the 
other  against  his  knee.  Since  that  time  both  luxation  and  reduction 
have  been  comparatively  easy,  and  the  patient  now  displaces  the  head 
of  the  bone  backward  upon  the  edge  of  the  socket  by  muscular  action, 
and  reduces  it  by  throwing  the  leg  out  sidewise.  The  luxation  is 
sometimes  attended  with  pain,  and  the  prominence  caused  by  the  head 
of  the  luxated  bone  is  sensitive  to  the  touch.  The  displacement  is 
rather  a  subluxation,  and  the  limb  exhibits  slight  flexion,  shortening, 
and  inversion." 

Dr.  Moore's  patient  was  a  soldier,  who,-  while  "  skirmishing  up  a 
hill,  sprang  back  suddenly  to  avoid  the  gun  of  a  comrade  in  advance. 
His  left  foot  became  entangled,  and  his  weight  dislocated  his  hip.  He 
felt  the  injury,  and  supposed  it  out  of  joint.  Some  comrades  pulled 
it  in.  He  immediately  resumed  skirmishing,  and  marched  seven  miles, 
from  10  A.M.  until  6  p.m.  He  lay  down  at  night,  and  went  on  duty 
the  next  day,  sharp-shooting,  crawling  all  day.  He  continued  this 
kind  of  duty  fiv^e  days,  and  returned  to  camp,  when  he  was  imme- 
diately put  in  intrenchments,  and  worked  two  days  and  two  nights. 
Afterward  he  went  on  picket,  and  entered  the  hospital  on  the  sixteenth 
day  after  the  accident.  At  present  he  can  luxate  the  hip-joint  at  any 
time,  and  does  it  by  pressing  the  foot  on  the  floor  to  fix  it  firmly,  con- 
tracting the  adductors,  and  throwing  out  the  pelvis.  The  head  sud- 
denly leaves  the  acetabulum  and  goes  on  the  dorsum  ilii." 

As  no  autopsy  has  been  reported  in  any  such  case,  the  explanation 
of  the  peculiarity  can  only  be  inferred.  It  is  probable  that  the  rent  in 
the  capsule  is  insufficiently  repaired,  and  the  edge  of  the  acetabulum 
lowered  at  the  point  where  the  head  of  the  femur  escapes. 

1  Perier :  Bull,  de  la  Soc.  de  Chir.,  1859,  vol.  x.  p.  12.  ^  Bigelow :  The  Hip,  p.  112. 


DISLOCATIONS  OF  THE  HIP.  859 

TREATMENT    OF    OLD,  UNREDUCED   DISLOCATIONS.^ 

The  reduction  of  an  old  dislocation  of  the  hip  is  a  serious  under- 
taking. The  distance  to  which  the  head  of  the  femur  is  conimonlv 
displaced,  the  consequent  shortening  of  powerful  muscles,  and  the 
numerous  adhesions  often  require  the  use  of  much  force,  and  the  rela- 
tively small  size  of  the  cotyloid  cavity  and  its  easy  obstruction  by  por- 
tions of  the  capsule  or  new-formed  fibrous  tissue  or  fragments  of  its 
rim  make  the  lodgment  of  the  head  within  it  difficult  or  impossible, 
even  if  it  can  be  brought  opposite  it.  Adhesions  can  be  broken  by 
manipulation  and  muscles  can  be  stretched  by  traction,  but  the  acetabu- 
lum can  be  cleared  only  by  arthrotoray.  The  methods  available  are 
reduction  by  manipulation  and  traction  or  by  arthrotomy  and  improve- 
ment of  the  attitude  of  the  limb  and  function  by  non-operative  shift- 
ing of  the  head,  resection,  or  osteotomy. 

Manipulation  and  traction.  The  records  contain  reports  of  alleged 
reduction  by  this  means  after  intervals  of  considerable,  sometimes  even 
great,  length,  but  in  most  of  them  it  remains  questionable  whether  re- 
duction was  actually  made,  whether  the  head  was  not  merely  brought 
nearer  to  the  cotyloid  cavity  and  the  limb  into  a  better  position.  The 
records  also  show  that  the  practice  is  far  from  being  devoid  of  risk  to 
life,  several  patients  having  succumbed  to  shock  or  suppuration  and 
others  having  narrowly  escaped.  The  propriety  of  the  attempt  is  to 
be  determined  not  merely  by  the  length  of  time  that  has  elapsed,  but 
also  by  tiie  distance  to  which  the  head  has  been  displaced  and  its 
mobility,  the  amount  of  the  antecedent  reaction,  ar-ray  indications  as  to 
associated  fractures,  and  the  age  and  strength  of  the  patient.  The 
general  plan  is  to  mobilize  the  head  by  moving  the  limb  in  various 
directions,  and  then  after  having  brought  it  to  what  is  deemed  the 
most  favorable  position  to  draw  it  into  place  by  forcible  traction,  usu- 
ally by  pulleys,  aided  by  such  manipulations  as  are  indicated.  In  sev- 
eral cases  the  neck  has  been  broken  during  the  attempt. 

The  results,  even  when  the  reduction  has  been  made,  are  not  brilliant ; 
function  is  improved  by  the  better  attitude  of  the  limb,  but  the  range 
of  motion  is  usually  much  restricted.  In  part  this  appears  to  be  due 
to  damage  done  to  the  head  and  its  cartilage  during  the  manipulations. 
Of  46  cases  collected  by  Piollet  [These  de  Lyon,  1903,  quoted  by 
Cahier  in  Xouveau  Traite  de  Chir.,  fasc.  6)  reduction  was  made  in  35, 
with  1  death,  and  failed  in  11,  with  4  deaths  and  8  fractures  of  the 
neck  or  shaft,  a  mortality  of  more  than  10  per  cent.      Probably  a  better 

I  Frjr  bibliography  see  1st  edition  :  Kirn,  Beitriige  zur  kiln.  Chir.,  1889,  vol.  iv.  p.  537; 
Harris,  Annals  of  Surgery,  September,  1894  ;  Engcl,  Arch.  fUr  klin.  Chir.,  1897,  p.  629; 
Sherman,  Phil.  Med.  .Jour.,  August  20.  1898;  Hoflinger,  Centralblatt  fiir  Chir..  1901,  p. 
.310;  Payr,  Deutsche  Ztschft.  fiir  Chir.,  1900,  vol.  Ivii.  ;  Gayet,  Eevue  de  Chir.,  1902, 
vol.  xxvi.  pji.  41  and  269.  29  cases;  Mavdl,  Centralblatt  fiir  Chir.,  1903,  p.  678,  lr>  cases; 
Rydygier,  ibid.,  1904,  377;  Endlich.  Arch,  fiir  klin.  Chir.,  1898,  vol.  hi.  p.  ri74  ;  Stcisslcr, 
Beitrage  zur  klin.  Chir.,  1908,  vol.  Iviii.  p.  571  ;  Lorenz,  Gcsellschaft  fiir  Ortliop.  Chir., 
7th  Congress,  1908,  p.  287;  Dollinger,  Ergebnisse  dcr  Chir.  und  Orthop.,  1911,  vol.  iii. 
Resection:  Delagarde,  St.  Bartholomew's  Hospital  Reports.  1866,  vol.  ii.  p.  183;  Sydney 
Jones,  Lancet,  1884,  vol.  ii.  p.  s70 ;  Rafimow.  St.  Petersburg  Med.  Wochenschrift,  .Ttily  30, 
188.-S;  firaziaiia.  Centralblatt  fiir  Chir.,  1^90.  p.  244 ;  Kammerer,  Medical  Record,  March 
4,  1893  ;  Flower,  British  Medical  .Journal,  Nov.  2,  l-'95  ;  Browne,  ibid.,  February  15,  1S96  ; 
Ostermayer,  Centralblatt  fur  Chir.,  May  11,  1895;  Paci,  Arch.  Italian,  de  I'ediat.,  vol.  vii. 


860  DISLOCATTOXS. 

idea  of  its  range  of  availability  is  given  by  Dollinger's  22  personal 
cases  more  than  three  weeks  old ;  the  attempt  was  made  in  all  which 
held  out  any  prospect  of  success,  and  it  succeeded  in  only  5  (four,  six, 
seven,  eight,  nine  weeks)  ;  the  rest  were  treated  by  operation. 

Lorenz,  quoting  Paci,  Cordivilla,  and  Goldman  in  support,  and  also 
experience  in  congenital  dislocations,  strongly  urges  non-operative  par- 
tial reduction,  by  which  the  head  is  brought  in  front  of  and  a  little 
above  the  acetabulum,  or  the  posterior  side  of  the  neck  is  brought 
against  it,  a  method  which  he  terras  transposition.  He  reports  one 
case  thus  treated  with  a  fairly  satisfactory  functional  result,  but  the 
change  was  effected  only  by  the  prolonged  use  of  great  force,  and  the 
shock  was  so  great  that  for  a  day  or  two  the  patient's  life  was  in  danger. 

I  doubt  if  the  plan  carries  less  risk  or  the  ]>romise  of  better  function 
than  arthrotomy  or  osteotomy  in  competent  hands,  or  even  than  resec- 
tion in  obturator  or  pubic  dislocations. 

Reduction  by  artkrotomy  was  first  tried  by  Volkmann,  in  1877,  in  an 
obturator  transf  )rraed  by  manipulation  into  a  dorsal  dislocation  ;  it 
failed,  and  resection  was  done  just  above  the  lesser  trochanter  with  a 
fair  functional  result.  In  1878  MacCormac  repeated  the  experience, 
and  in  1882  Polaillou  made  the  first  successful  reduction  in  a  dorsal 
dislocation  about  seven  weeks  old,  but  the  patient  died  of  sepsis.  From 
this  unpromising  beginning  the  operation  has  advanced  with  growing 
frequency  to  a  fair  measure  of  success.  Piollet,  in  1903,  collected  28 
cases  (13  children  or  youths,  15  adults),  the  dislocation  less  than  six 
months  old  in  all  but  one,  with  3  deaths,  5  suppurations,  7  ''  perfect," 

II  fair,  and  6  mediocre  results.  Streissler,  1908,  collected  22  arthroto- 
mies  in  "anterior"  (obturator  and  pubic)  dislocations,  of  w^hich  11 
were  resections  and  2  osteotomies,  with  2  deaths  and  3  suppurations, 
both  deaths  following  reduction.  Dollinger's  12  cases  of  reduction 
gave  no  death  and  6  suppurations,  in  5  of  which  the  head  was  stibse- 
quently  resected ;  his  last  5  cases  healed  without  suppuration,  an  im- 
provement due,  he  thinks,  to  changes  in  technique  growing  out  of  the 
experience  gained  in  the  previous  cases.  Few  surgeons  have  had  more 
than  a  single  case,  so  that  the  opportunity  to  develop  an  advantageous 
method  has  been  restricted.  Dollinger's  12  operations  came  from  22 
cases  received  into  his  service  at  Buda-Pest  between  1897  and  1910, 
and  he  quotes  Payr  as  having  had  7,  Mikulicz  4,  and  Riedel  3.  Of 
Dollinger's  22  cases,  5  were  reduced  withotit  operation,  12  reduced  by 
operation,  with  5  subsequent  resections  of  the  head,  in  4  primary  re- 
section was  done,  with  1  death,  and  in  1  osteotomy. 

An  anterior  incision,  on  either  side  of  the  sartorius,  has  been  used  in 
a  few  cases,  but  in  the  great  majority  the  approach  has  been  from  be- 
hind, throttgh  the  gluteus  maximus,  and  in  a  few  the  great  trochanter 
has  been  temporarily  detached  with  its  muscles  for  the  better  exposure 
of  the  acetal)ulum. 

Dollinger's  incision  extended  from  the  base  of  the  trochanter  to  the 
posterior  inferior  spine  of  the  ilium  ;  through  this  the  fibres  of  the 
gluteus  maximus  were  drawn  aside,  and  the  head  of  the  femur,  in  dorsal 
dislocations,  exposed.  By  gentle  inward  rotation  of  the  limb  the  head 
is  raised  from  its  place,  the  pyriformis  and  obturator  internus  are  drawn 


DISLOCATIONS  OF  THE  HIP.  861 

aside,  or  divided,  if  necessary,  and  this  gives  an  access  to  the  acetabulum 
which,  though  restricted,  is  sufficient  if  a  head  mirror  is  used.  Great 
care  must  be  taken  not  to  strip  or  bruise  the  head  and  neck  of  the 
femur,  for  "skeletonizing"  of  the  bone  is  a  prime  cause  of  failure. 
After  the  acetabulum  has  been  cleared  reduction  is  made  by  circum- 
duction of  the  limb,  guided  by  the  eye  and  supplemented  if  necessary 
by  traction. 

In  the  obturator  dislocations  he  used  the  same  incision,  but  approached 
the  acetabulum  from  above  the  external  rotators  instead  of  from  below, 
unless  their  division  was  necessary  ;  and  if  the  head  was  too  firmly 
fixed  in  place  to  be  turned  back  by  manipulation  he  exposed  it  by  a 
second  incision  directly  upon  it  from  below,  the  hip  being  flexed. 

Rydygier  used  a  convex  incision,  passing  from  near  the  posterior  in- 
ferior spine  to  a  point  two  and  a  half  inches  below  the  tip  of  the  tro- 
chanter and  then  upward  toward  the  anterior  superior  spine ;  he  then 
cut  the  trochanter  off  obliquely  with  its  attached  muscles  and  thus  ob- 
tained free  access  to  the  acetabulum.  After  reduction  the  trochanter 
was  secured  in  place  by  a  nail. 

Resection  of  the  head  has  been  resorted  to  about  as  frequently  as  re- 
duction by  arthrotomy,  either  primarily  or  after  failure  to  reduce.  It 
is  a  less  difficult  and,  in  ordinary  bauds,  a  less  dangerous  operation. 
Some  of  the  functional  results  are  fairly  good,  but  in  others  little  effect- 
ive use  could  be  made  of  the  limb.  Apparently  the  result  is  better  in 
obturator  than  in  dorsal  dislocation,  presumably  because  the  upper  end 
of  the  femur  finds  better  support  upon  the  ilium. 

Osteotomy,  through  or  below  the  neck,  has  been  done  in  a  few  cases 
with  the  object  of  giving  a  better  attitude  to  the  limb  and  possibly 
some  mobility  if  the  pieces  do  not  reunite ;  and  fracture  of  the  neck 
accidentally  caused  during  attempted  reduction  has  been  taken  advan- 
tage of  in  the  same  way.  Necrosis  of  the  head  has  followed  such 
fracture  or  division  in  a  few  cases. 

As  between  the  different  operative  methods  successful  reduction  by 
arthrotomy  gives  the  best  results  and  is  most  likely  to  be  obtained  in 
the  young ;  but  if  anchylosis  follows,  as  it  has  not  infrequently  done, 
either  because  of  suppuration  of  the  wound  or  of  peri-articular  ff)rma- 
tion  of  bone,  the  functional  result  may  be  no  better  than  that  following 
osteotomy  or  resection.  In  the  lack  of  experience  in  the  operation,  the 
value  of  which  appears  so  clearly  in  the  records,  the  surgeon  w^ho  un- 
dertakes reduction  should  plan  the  operation  carefully,  and  execute  it 
with  rigid  attention  to  asepsis  and  with  the  minimum  of  dissecti(m  near 
the  bone  and  of  handling  of  the  parts.  Non-operative  reduction  may 
properly  be  attempted  when  the  head  is  not  far  removed  from  its 
socket  and  is  fairly  movable,  and  when  the  dislocation  has  not  existed 
for  more  than  two  months,  but  the  attempt  should  not  be  greatly  pro- 
longed, and  if  in  its  course  the  limb  should  be  brought  to  an  attitude 
in  which  it  is  likely  to  be  fairly  useful  (Tvorenz's  transposition)  the  sur- 
geon may  well  rest  satisfied  with  that  gain.  It  should  be  borne  in  mind 
that  the  mortalitv  of  ])rolong(Ml,  persistent  attempts  to  reduce  has  been 
high,  as  high  as  that  of  operative  reduction. 

In  deciding  whether  or  not  to  interfere  in  an  old  case,  and  in  choosing 


862  DISLOCATIONS. 

a  method  if  interference  is  determined  upon,  several  things  beside  the 
mere  fact  of  the  existence  of  the  dislocation  must  be  considered.  If 
the  limb  is  useful,  if  the  patient  is  not  suifering  from  pressure  effects, 
and  if  he  is  no  longer  young,  prudence  will  often  dictate  abstention. 
Quieta  non  movere  !  Or,  at  the  most,  an  osteotomy  may  be  done  to 
bring  the  limb  into  a  more  convenient  and  serviceable  position.  If  the 
patient  is  younger,  if  the  disability  is  greater,  if  the  position  of  the 
head  causes  serious  pressure  effects,  reduction  by  arthrotomy  may  be 
attempted,  with  the  determination  to  abandon  the  attempt  if  it  proves 
difficult  and  to  substitute  excision.  But  the  surgeon  must  carefully 
consider  the  present  usefulness  of  the  limb,  the  probability  of  the  use- 
fulness that  will  follow  the  interference,  and  the  risk  to  life  incurred  in 
the  attempt  to  improve. 

CONGENITAL    DISLOCATIONS. 

(See  Chapter  XXXV.) 

SPONTANEOUS  OR  PATHOLOGICAL  DISLOCATIONS. 

Almost  all  the  different  kinds  of  spontaneous  dislocation  have  been 
observed  at  the  hip,  and  many  of  them  with  a  frequency  that  has  not 
been  observed  at  other  joints.  The  weight  of  the  body  in  walking  is 
a  factor  of  much  importance  and  constantly  at  work,  the  effect  of 
which  is  well  shown  in  three  cases  reported  by  Liicke,^  in  which  the 
dislocation  followed  rhachitic  changes  in  the  shape  of  the  femurs  and 
the  spinal  column.  The  patients  were  children  who,  at  birth  and 
during  infancy,  showed  no  sign  of  dislocation ;  after  a  time  rhachitic 
changes  occurred,  the  displacement  appeared ;  and  walking  became 
difficult.  Llicke  found  a  marked  lumbar  lordosis  and  anterior  curva- 
ture of  the  femurs ;  the  trochanters  were  displaced  far  backward,  and 
the  dislocation  was  evident.  He  thought  the  curvature  of  the  femurs 
was  the  primary  change,  and  the  lordosis  compensatory  of  it,  and  that 
the  dislocation  was  due  to  changes  in  the  acetabulum  following  the  con- 
sequent pressure  at  an  unusual  point. 

Of  similar  character  are  those  cases  in  which  the  dislocation  has 
taken  place  in  a  healthy  joint  in  consequence  of  the  prolonged  main- 
tenance of  some  exceptional  attitude,  as  in  a  case  reported  by  Franks  ^ 
of  a  child  five  years  old,  who  had  been  confined  to  the  bed  for  many 
months  by  an  arthritis  of  the  left  hip,  and  had  lain  upon  its  left  side 
with  the  knees  and  hips  flexed,  and  the  right  hip  adducted ;  a  dorsal 
dislocation  took  place  without  pain  on  the  right  side.  Here  the  con- 
traction of  the  muscles  takes  the  })lace  of  the  weight  of  the  body  in 
producing  the  dislocation  when  the  limb  is  long  held  in  a  favorable 
attitude,  and  many  examples  of  this  effect  have  been  reported  in  cases 
in  which  the  joint  was  the  seat  of  an  arthritis,  as  in  acute  articular 
rheumatism,  or  in  continued  fevers,  typhoid,  scarlatina,  in  which  usu- 
ally there  are  indications  of  inflammation  of  the  joint,  although  in 

1  Liicke :  Quoted  by  Forgue  and  Maubrac,  Luxations  pathologiques,  Paris,  1886, 
p.  15. 

-  Franks :  Lancet,  1883,  vol.  ii.  p.  15. 

•' Stromeyer :  Handbuch  der  Chir.,  1844,  vol.  ii.  quoted  by  Foi-gue  and  Maubrac. 


DISLOCATIONS  OF  THE  HIP.  863 

some  cases  attention  was  first  called  to  the  joint  by  the  appearani-e  of 
the  deformity,  (See  p.  554.)  As  the  individual  usually  lies  with  the 
thi^h  flexed  and  adducted,  the  dislocation  almost  always  takes  place 
backward  and  upward  ;  but  in  a  case  observed  by  Stromeyer,'  a  man 
eiijhteen  vears  old,  affected  with  acute  articular  rheumatism,  especially 
of  the  hip,  durino'  the  entire  course  of  which  he  had  lain  on  his  side,  the 
dislocati(m  was  into  the  obturator  foramen. 

''  Paralytic "  or  "  myopathic "  dislocations  of  the  hip,  those  in 
which  the  displacement  is  effected  by  the  unopposed  contraction  of  cer- 
tain muscles  or  groups  of  muscles,  whose  antagonists  are  paralyzed, 
have  been  most  frequently  seen  as  a  consequence  of  infantile  paralysis. 
As  has  been  shown  in  Chapter  XXXVI.  they  were  formerly  con- 
founded with  congenital  dislocations,  and  were  first  clearly  separated 
from  them  by  Verneuil,2  and  afterward  studied  in  detail  by  some  of 
his  pupils,  especially  Reclus.^  When  the  paralysis  involves  all  the 
muscles  of  the  hip  the  joint  becomes  loose,  and  the  femur  may  be  dis- 
placed and  replaced  at  will,  but  when  only  a  part  of  the  muscles  are 
paralyzed  the  contraction  of  the  others  leads  to  a  permanent  displace- 
ment. If  the  posterior  muscles  are  paralyzed,  and  the  adductors 
remain  in  good  condition,  the  dislocation  is  dorsal ;  if  the  adductors 
are  paralyzed  and  the  glutei  remain  sound,  the  dislocation  is  forward 
upon  the  pubis.  One  of  the  cases  observed  by  Reclus  may  be  taken 
as  a  good  example  of  one  form ;  a  child,  which  had  previously  been 
healthy  and  well  formed,  was  attacked  at  the  age  of  seven  years  with 
high  fever  and  a  paralysis  which,  at  first  general,  became  localized  in 
the  glutei  and  the  other  pelvi-trochanteric  muscles ;  the  other  groups, 
especially  the  adductors  of  the  thigh,  recovered  their  activity  ;  a  well- 
marked  dorsal  dislocation  followed.* 

In  a  case  reported  by  Bradford,^  a  girl,  eighteen  months  old,  the 
right  thigh  was  flexed  and  abducted  at  a  right  angle,  the  adductors 
were  paralyzed,  the  glutei  and  tensor  vaginae  femoris  sound.  The  head 
of  the  femur  could  be  felt  in  the  groin  upon  the  superior  ramus  of  the 
pubis  midway  between  the  symphysis  and  the  anterior  superior  spine 
of  the  ilium.  Reduction  was  effected,  but  the  limb  remained  almost 
powerless. 

The  cases  should  be  treated  by  prompt  reduction,  if  possible,  and 
the  maintenance  of  the  limb  in  an  attitude  that  opposes  recurrence. 

In  three  cases  reported  by  Roser^  in  1885,  at  the  Congress  held  at 
Strasburg,  the  paralysis  was  due  to  spinal  disease  ;  in  one  of  them  the 
patient  produced  the  dislocation  by  swinging  his  legs  forward  while 
walking  with  crutches  ;  in  the  other  two  the  dislocation  took  place  in 
bed  witliout  appreciable  cause. 

The  limitation  of  the  paralysis  to  one  group  of  muscles  is  to  be 
explained  by  the  fact  that  the  adductors  are  supplied  by  the  obturator 
nerve,  a  branch  of  the  lumbar  plexus,  and  the  posterior  muscles  by 

1  Stromcyer:  Handbucli  dcr  Chir.,  1844,  vol.  ii.,  quoted  by  Forgue  and  Maubrac. 

2  Vcrnoiiil  :  Bull,  do  la  Socicte  de  CliirurKio,  18()6. 
»  Reclus:  Ecvuf  <lc  Mrd.  ct  de  Cliir.,  isis,  p.  176. 

*  See  papei-  by  Karewski,  Arch,  fiir  kliu.  Cliir.,  1H88,  vol.  .\x.\vii.  p.  :;4(}. 

*  Bradford  :   Boston  Medical  ami  Sur;,ncal  Journal,  188:5,  vol.  cviii.  j).  T.'J. 
5  Eoser:  Quoted  by  Forgue  and  Maubrac.  loc.  cit.,  p.  43. 


864  DISLOCATIONS. 

branches  of  the  sacral  plexus,  and  that  the  medullary  centres  of  these 
nerves  are  at  different  points  in  the  cord,  that  of  the  former  being  at 
a  higher  point  than  the  other,  probably  at  the  upper  part  of  the  lumbar 
enlargement. 

Dislocations  due  to  destruction  of  the  bony  parts  of  the  joint  by 
tubercular  disease  are  comparatively  common ;  their  consideration 
belongs  rather  to  the  subject  of  disease  of  the  hip-joint. 

In  like  manner  the  consideration  of  those  dislocations  which  follow 
changes  in  the  bones  produced  by  chronic  rheumatism  or  dry  arthritis 
or  in  ataxia  belongs  to  works  upon  those  subjects.  The  alterations  in 
the  shape  of  the  bones,  either  by  atrophy  or  by  hypertrophy,  are 
so  marked  that  reduction  or  maintenance  of  reduction  is  impossible. 
In  diy,  or  deforming,  arthritis  not  only  are  all  the  constituent  parts  of 
the  joints  involved  in  the  changes,  but  the  muscles  also  become  degen- 
erated ;  the  bones  are  usually  hypertrophied  by  outgrowths  at  the  bor- 
ders of  the  articular  surfaces,  they  lose  their  articular  cartilage,  and 
become  eroded  at  points  of  contact.  The  changes  in  locomotor  ataxia 
are  characterized  by  early  and  rapid  atrophy  of  the  head  and  neck  of 
the  femur  with  destruction  to  a  greater  or  less  extent  of  the  rim  of  the 
acetabulum.  Sometimes  dislocation  takes  place  abruptly  with  well- 
marked  and  characteristic  symptoms ;  in  other  cases  the  symptoms  are 
more  like  those  of  fracture  of  the  neck  of  the  femur,  the  foot  is  everted 
and  the  trochanter  raised,  but  the  movements  are  exceptionally  free 
and  may  be  painless. 


CHAPTER  LIV. 

DISLOCATIONS  OF  THE  KNEE. 

Forward — Backward — Lateral — Antero-lateral — By  Rotation — Dislocation  of 
the  Semilunar  Cartilages — Congenital — Spontaneous  or  Pathological  Dis- 
locations. 

Anatomy. 

The  knee-joint  may  be  regarded  as  composed  of  two  joints,  of 
which  one  is  formed  by  the  patella  and  femur,  the  other  by  the  femur 
and  tibia ;  and  the  latter  is  composed  of  two  parts,  differing  somewhat 
from  each  other,  each  of  which  is  formed  by  one  of  the  condyles  of  the 
femur  and  the  corresponding  portion  of  the  up})er  surface  of  the  tibia. 
The  condyles  of  the  femur  are  separated  from  each  other  by  the  inter- 
condylar notch,  and  between  the  condylar  surfaces  of  the  tibia  is  a 
depression  which  is  interrupted  in  the  centre  by  the  spine. 

The  ligaments  which  bind  the  femur  to  the  tibia  and  fibula  are  the 
external  and  internal  lateral,  the  posterior,  and  the  crucial.  The 
internal  lateral  ligament,  long  and  flat,  extends  from  the  internal 
tuberosity  of  the  femur  to  the  inner  side  of  the  shaft  of  the  tibia ;  the 
external  lateral,  more  rounded  and  cord-like,  extends  from  the  exter- 
nal tuberosity  of  the  femur  to  the  head  of  the  fibula,  overlying  the 
tendon  of  the  popliteus  above  and  being  embraced  by  the  tendon  of  the 
biceps  below.  The  short  external  lateral  ligament,  lying  somewhat 
more  deeply  and  posterior  to  the  other,  is  attached  above  to  the 
side  of  the  condyle  and  below  to  the  styloid  process  of  the  fibula.  The 
posterior  ligament  is  attached  above  to  the  upper  part  of  the  intercon- 
dylar fossa  of  the  femur  and  below  to  the  posterior  margin  of  the 
head  of  the  tibia.  The  crucial  ligaments  extend  from  either  side  of 
the  intercondylar  notch  to  the  depression  in  front  of  and  beliind  the 
spine  of  the  tibia.  In  full  extension  of  the  knee  those  ligaments  are 
made  tense,  but  in  flexion  at  a  right  angle  the  lateral  ones,  especially 
the  external  lateral,  are  relaxed. 

The  semilunar  fibro-cartilages  are  intra-articular  structures  attached 
to  the  head  of  the  tibia  at  their  outer  margins  nnd  ends  and  having 
free  smooth  surfaces  above  and  below;  tliey  are  triangular  on  vertical 
section,  the  periphcrnl  border  being  tliick,  tiie  central  tliin  ;  as  they  are 
rings,  not  disks,  each  leaves  the  corresponding  condylar  surface  of  the 
tibia  uncovered  at  the  centre.  The  internal  one  is  semicircular,  and 
its  ends  are  attached  in  front  of  and  behind  tiie  spine  of  the  tibia 
respectively  ;  the  external  one  is  nearly  a  complete  circle,  and  its  ends 
are  attached  to  the  spine  of  the  tibia  between  those  of  the  internal  one, 
its  posterior  end  is  also  attached  to  the  inner  condyle  of  the  femur  in 
connection  with  the  posterior  crucial  ligament.    The  external  cartihige 

(865) 


866  DISLOCATIONS. 

is  movable  upon  the  tibia,  this  freedom  of  motion  being  utilized  in  the 
outward  rotation  of  the  leg  which  occurs  at  the  end  of  extension,  while 
the  internal  one  is  more  fixed  and  serves  mainly  to  make  a  more  con- 
cave surface  for  articulation  with  the  internal  condyle  of  the  femur. 
The  anterior  borders  of  the  two  cartilages  are  connected  together  by 
a  slight  transverse  band,  the  transverse  ligament ;  it  is  sometimes 
lacking. 

The  capsular  membrane  fills  the  gaps  between  the  ligaments.  It  is 
reinforced  on  each  side  by  broad  fibrous  sheets  attached  to  the  sides  of 
the  patella  and  derived  from  the  fascia  lata  and  the  muscles,  the 
so-called  lateral  expansions. 

The  synovial  membrane  extends  w^ell  up  on  the  front  of  the  thigh, 
frequently  communicating  with  a  bursa  under  the  quadriceps,  and 
invests  the  crucial  ligaments  by  a  reflection  from  the  posterior  wall. 
Between  the  tibia  and  patella  it  rests  upon  a  mass  of  fat,  forming  two 
lateral  folds,  the  alar  ligaments,  and  sending  backward  from  its  middle 
another  fold,  the  Hgamentum  mucosum,  which  is  attached  to  the  front 
of  the  intercondylar  notch.  By  these  folds  and  the  crucial  ligaments 
the  joint  is  divided  into  three  more  or  less  freely  communicating  com- 
partments. 

Functionally,  the  femoro-tibial  joint  is  a  ginglymo-arthrodial,  its 
movements  being  effected  by  a  combination  of  gliding,  rolling,  and 
rotation  of  the  bones  upon  each  other.  In  complete  extension  no  rota- 
tion is  possible,  but  as  the  knee  is  flexed  outward  rotation  appears  and 
increases,  reaching  21  degrees  at  rectangular  flexion  and  31  degrees  at 
flexion  30  degrees  within  a  right  angle.     (Mayer.) 

In  complete  extension  the  patella  rests  upon  the  upper  part  of  the 
trochlear  surface  of  the  femur,  and  as  flexion  is  made  it  moves  down- 
ward and  is  gradually  turned  outward  by  the  increasing  prominence  of 
the  internal  condyle,  so  that  at  the  last  it  rests  by  its  upper  and  outer 
facet  on  the  front  of  the  external  condyle  and  by  its  inner  facet  against 
the  narrow  surface  of  the  outer  margin  of  the  internal  condyle.  As 
the  movement  of  extension  approaches  its  limit  the  tibia  undergoes 
slight  outward  rotation  in  which  the  external  semilunar  cartilage  does 
not  participate,  that  is,  the  outer  condylar  surface  of  the  tibia  moves 
backward  under  the  fibro-cartilage  ;  correspondingly,  when  flexion  is 
begun  from  the  position  of  complete  extension  it  is  accompanied  by 
inward  rotation  of  the  tibia.  The  limitation  of  extension  is  affected 
by  the  posterior  and  lateral  ligaments,  that  of  flexion  by  the  contact  of 
the  soft  parts  of  the  calf  and  thigh  and  of  the  posterior  margin  of 
the  semilunar  cartilages  with  the  back  of  the  condyles  of  the  femur. 
Displacement  of  the  tibia  forward,  backward,  or  to  either  side  is  op- 
posed by  the  lateral  and  crucial  ligaments. 

Statistics. 

Dislocations  of  the  knee,  of  the  femoro-tibial  joint,  are  rare,  con- 
stituting about  1  per  cent,  of  all  cases.  They  are  divided  according 
to  the  direction  in  which  the  tibia  is  displaced  \\\io  forward,  backward, 
outward,  and  imvard  dislocations,  and  dislocations  by  rotation.     Mai- 


DISLOCATIONS  OF  THE  KNEE.  807 

gaigne  made  additional  groups  of  intermediate  forms.  The  disloca- 
tion may  be  complete  or  incomplete,  simple  or  compound.  A  tabula- 
tion which  I  made  by  the  aid  of  the  references  to  periodical  literature 
in  the  Index- Catalogue  of  the  Surgeon- General's  Library  showed  that 
of  114  traumatic  cases  the  dislocation  was  forward  in  52,  backward 
in  34,  outward  in  21,  inward  in  4,  'Materal  "  in  1,  and  by  rotation 
in  3.  In  21  of  them  the  dislocation  was  compound ;  11  forward,  4 
backward,  6  outward. 

The  injury  is  very  rare  in  childhood,  the  two  youngest  patients  in 
my  list  being  aged  ten  and  eleven  respectively  ;  it  is  of  exceptional 
gravity  because  of  the  size  of  the  joint,  because  it  is  usually  caused  by 
great  violence,  and  because  of  the  frequency  with  which  it  is  compound 
and  with  which  the  popliteal  vessels  are  injured.  Amputation  has  been 
resorted  to  in  a  large  proportion  of  cases.  Simultaneous  dislocation 
of  both  knees  has  been  observed  in  a  few  cases. 

DISLOCATIONS  FORWARD. 

These  may  be  complete  or  incomplete,  simple  or  compound.  The 
complete  seem  to  be  very  much  rarer  than  the  incomplete ;  the  com- 
pound occur  in  an  exceptionally  large  proportion,  18  per  cent,  in  the 
tabulation  just  given,  and  the  wound  is  habitually  made  by  rupture  of 
the  soft  parts  posteriorly  where  they  are  stretched  across  the  projecting 
condyles  of  the  femur  in  hyperextension  of  the  leg. 

The  cause  may  be  either  hyperextension  of  the  leg,  or  violence 
received  upon  the  front  of  the  thigh  or  the  back  of  the  leg  near  the 
knee.  The  former  appears  to  be  much  the  more  common  ;  in  it  the 
tibia  turns  upon  its  anterior  margin  as  a  centre,  putting  the  posterior, 
lateral,  and  crucial  ligaments  upon  the  stretch,  and  after  their  rupture 
it  glides  forward  along  the  condyles,  or  the  condyles  slide  backward 
along  it.  The  hyperextension  may  be  produced  by  a  force  applied  to 
the  back  of  the  leg  or  foot,  or,  more  commonly,  by  the  propulsion  of 
the  trunk  and  thigh  while  the  leg  is  held  stationary  and  upright ; 
thus,  a  man  running  down  a  hill  steps  into  a  hole,  the  leg  entering  to 
its  upper  third,  and  falls  forward.  In  a  case  of  my  own  the  patient, 
a  large  heavy  man,  was  standing  in  an  elevator  which  was  sud- 
denly stop])e(l  while  descending  rapidly;  he  received  the  dislocation 
without  falling  or  being  struck,  apparently  by  hyperextension  of  the 
knee.  The  tibia  overrode  the  femur  one  and  a  half  inches.  The 
other  cause,  direct  violence,  may  act  upon  the  fnmt  of  the  knee  while 
the  leg  is  either  extended  or  partly  flexed.  In  another  set  of  cases, 
of  which  I  have  met  with  tlie  records  of  four  examples,  the  mode  of 
production  is  not  clear;  the  patients  were  caught  in  rapidly  revolving 
wheels  or  shafts  and  whirled  around  many  times,  the  body  passing  at 
some  part  of  its  course  through  a  narrow  space  ;  in  three  of  these  cases 
both  knees  were  dislocated,  in  two  of  them  one  dislocation  being  for- 
ward, the  other  backward,  and  In  the  third  one  dislocation  was  forward 
and  the  other  inward. 

In  a  case  of  my  own  in  which  the  j)atient  was  similarly  caught  by 


868  DISLOCATIONS. 

a  shaft  he  was  wedged  against  the  ceiling,  but  not  carried  through, 
receiving  forward  dislocations  of  both  knees,  one  compound  on  the 
inner  side  with  rupture  of  all  the  internal  hamstring  muscles  through 
their  fleshy  parts  well  above  the  joint.  He  made  a  good  recovery,  but 
eight  months  later  paralysis  of  the  external  popliteal  group  persisted 
on  one  side,  and  control  of  the  knee  was  defective  on  the  side  on  which 
the  muscles  had  been  torn.  With  the  aid  of  a  brace  for  that  knee  and 
a  rubber  muscle  for  the  paralyzed  anterior  tibial  group  he  was  able  to 
walk  and  work. 


Fig.  465. 


Anterior  dislocation  of  the  knee. 

In  a  case  reported  by  Cotton  ^  the  ligaments  of  the  joint  had  gradu- 
ally grown  so  weak  that  the  knees  bent  backward ;  as  the  patient  got 
out  of  bed  one  morning  a  compound  dislocation,  with  rupture  of  the 
popliteal  artery,  was  produced. 

Pathology.  In  the  incomplete  form,  that  in  which  the  upper  articu- 
lar surface  of  the  tibia  is  still  in  contact  by  its  posterior  portion  with 
the  inferior  surface  of  the  condyles,  the  injury  to  the  ligaments  and 
other  soft  parts  appears  to  be  slight ;  in  the  only  autopsy,  one  reported 
by  Desormeaux,^  the  anterior  crucial  ligament  alone  was  torn,  and  that 
only  in  part.  In  the  complete  form,  on  the  other  hand,  the  injuries 
are  very  extensive  ;  one  or  both  lateral  ligaments,  one  or  both  crucial, 
the  posterior,  and  the  lateral  ligaments  of  the  patella  are  completely 
ruptured  or  widely  torn.  The  posterior  muscles,  the  biceps,  gastrocne- 
mius, popliteus,  even  the  soleus  and  vastus  internus  are  lacerated  or 

1  Cotton     Proceedings  of  the  Connecticut  Medical  Society,  1880,  vol.  ii.  p.  54. 

2  Desormeaux  :  Bull,  de  la  Soc.  de  Chirurgie,  1853,  vol.  iii.  p.  367. 


DISLOCATIONS  OF  THE  KNEE.  869 

divided ;  the  internal  and  external  popliteal  nerves  mav  ])e  torn  or 
bruised,  the  popliteal  artery  and  vein  ruptured,  the  skin  of  the  poplit- 
eal space  torn  through.  Sometimes  the  ligaments  are  ruptured,  souk-- 
times  they  are  torn  from  the  femur,  perhaps  bringing  with  them  por- 
tions of  the  bone;  the  protruding  condyles  appear  sometimes  as  if 
they  had  been  cleaned  with  a  knife.  The  overriding  of  the  tibia  and 
femur  may  amount  to  two  or  even  three  inches ;  in  Mayo's  ^  it  was  said 
to  be  fully  four  inches. 

The  injuries  to  the  popliteal  artery  are  of  exceptional  interest  and 
importance.  Its  inner  and  middle  coats  may  be  torn  completely  across 
(Annandale,  Cotton,  Knichynicki,^  Lowe,^'  two  cases,  Vevers,*  and 
Stewart  and  Turner,  quoted  by  Spillmann  ;  in  most  of  them  the  dislo- 
cation was  compound) ;  or,  as  in  a  case  examined  by  Malgaigne,  there 
may  be  several  small  rents  at  atheromatous,  calcareous  points.  The 
artery  may  be  simply  compressed  and  remain  competent  to  perform  its 
functions  when  the  pressure  is  removed  (Davis,^  Hixon^),  or  it  mav 
be  so  bruised  that  a  thrombus  will  subsequently  form  (Brittain).  The 
popliteal  vein  appears  from  the  reports  to  have  been  less  frequentlv 
torn,  but  when  bruised  it  also  may  become  occupied  by  a  thrombus. 
It  seems  probable  that  in  the  cases  in  which  gangrene  followed  the 
vein  as  well  as  the  artery  was  injured.  The  opportunities  for  direct 
examination  after  death  or  amputation  have  been  numerous ;  among 
the  reports  may  be  mentioned  those  by  Malgaigne,  Volkmann,^  Albert,^ 
Birkett,^  Annandale,^"  Brittain,"  Madelung,'^  Spillmann,^^  and  Lowe, 
above  quoted. 

Symptoms.  The  leg  is  usually  in  almost  complete  extension,  and 
when  viewed  from  the  side  it  is  seen  to  lie  in  a  plane  more  or  less  ante- 
rior to  that  of  the  thigh,  according  as  the  dislocation  is  complete  or 
incomplete ;  it  may  be  hyperextended  or  partly  flexed,  and  may  be 
rotated  in  either  direction.  The  outlines  of  the  projecting  condyles 
can  be  seen  and  felt  in  the  popliteal  space,  and  above  the  tibia  in  front 
lies  the  patella,  more  or  less  horizontal  and  freely  movable,  and  the 
skin  above  it  shows  marked  transverse  folds ;  the  flat  articular  surface 
of  the  tibia  can  be  felt  on  each  side  of  the  ligamentum  patella.  In 
the  incomplete  form  the  deformity  is  less  marked,  and  the  diagnosis 
may  be  difficult  if  the  region  is  swollen. 

The  limb  may  be  fixed  in  its  position,  or  it  may  be  movable  in  any 
direction,  hyperextension,  flexion  to  a  right  angle,  or  laterally. 

If  the   skin   is  broken    the   rent  is   transverse  and   posterior,   and 

1  Cooper :  Loc.  cit.,  p.  187. 

2  Knichynicki  :  Allj;.  Wiener  riied.  Zoitung,  1873,  vol.  xviii.  p.  25i5. 

3  Lowe :  St.  Bartholomew's  Hospital  Reports,  1869,  vol.  v.  p.  80. 

*  Vevers:  Lancet,  1869.  vol.  ii.  p.  .542. 

5  Davis  :  Philadelphia  Medical  Times,  1876-77.  vol.  vii.  p.  270. 

*  Hixon  :  Xorth  American  Medico-C'hirurgical  Review,  1858,  vol.  ii.  p.  76. 
'  Yolkniann:  Bcitrage  zur  Chir.,  p.  119. 

8  Albert:  Wiener  med.  Presse,  1872. 

9  Birkctt:  Lancet,  18.50,  vol.  ii.  p.  703. 

10  Annandale:  Lancet,  1881,  vol.  ii.  p.  903. 

1'  I'.rittain;  London  Medical  fiazctte,  1S:]6,  vol.  xviii.  p.  2.".7. 

^'^  Madehnig:  Berlin,  kliii.  Woclieiis<lirin.  l."^7.'). 

"  Spillmann  :  Diet,  encycloi).  des  Sc.  Med.,  art.  Genoii,  p.  600. 


870  DISLOCATIONS. 

through  it  one    or  both  condyles   may  project,  or  the  finger  can  be 

readily  passed  into  the  joint.    The 
Fig.  4bo.  main  vessels  and  the  internal  pop- 

^^^^^ liteal  nerve  commonly  lie  in  the 

intercondylar    notch,    and     may 
sometimes  be  plainly  visible. 

Injury  to,  or  compression  of, 
the  artery  is  shown  by  the  loss  of 
pulsation  in  the  arteries  of  the 
foot   and    ankle ;    injury   to    the 

External  condyle  of  femur         ^^         ^^^^^^     i  j^^^     ^^     Sensation     Or 

Anterior  dislocation  of  the  knee.  i  i    i    x         i  i 

numbness,  and,  later,  by  changes 
due  to  defective  nutrition  of  the  limb  and  by  pain,  sometimes  severe. 

The  course  after  injury  to  the  artery  is  well  shown  in  the  report  of 
Annandale's  case,  that  after  injury  to  the  nerve  in  Le  Dentu's.^ 
Annandale's  patient  complained  that  the  foot  felt  cold,  but  sensation 
in  the  toes  was  normal ;  the  dislocation  was  easily  reduced,  and  the 
patient  did  well  for  a  week  ;  then  it  was  noticed  that  the  foot  was  livid 
and  cold.  Two  days  later  blebs  had  appeared  upon  it,  and  the  discol- 
oration had  advanced  upon  the  leg ;  three  days  later  the  signs  of  gan- 
grene were  marked,  and  the  limb  was  then  amputated  above  the  knee. 
The  inner  and  middle  coats  of  the  popliteal  artery,  which  were  ather- 
omatous, were  torn  about  an  inch  above  its  bifurcation,  and  curled 
inward  ;  the  vessel  was  plugged  by  a  firm  clot. 

Le  Dentu's  patient,  a  man  twenty-seven  years  old,  was  caught  in 
the  belt  of  machinery  and  whirled  around  rapidly,  his  legs  striking 
each  time  against  the  ceiling ;  he  received  a  complete  dislocation  for- 
ward of  the  right  knee,  and  a  complete  backward  dislocation  of  the 
left  one  ;  the  latter  was  reduced  immediately,  the  former  on  the  next 
day.  On  the  nineteenth  day  the  patient  complained  of  sharp  pain  in 
both  legs,  and  on  examination  an  eschar  as  large  as  a  fifty-cent  piece 
was  found  on  the  left  calf,  and  another  over  the  right  tendo  Achillis ; 
the  former  healed  promptly,  the  latter  increased,  and  part  of  the  tendon 
sloughed.  The  pain  became  very  severe  in  the  right  leg,  it  was  neu- 
ralgic in  character,  a  sensation  of  numbness  with  darting  pain  in  the 
foot  and  sometimes  in  the  leg,  recurring  especially  at  night.  It  per- 
sisted until  the  thirty-fifth  day,  and  returned  a  week  later.  On  the 
forty-fifth  day  another  eschar  appeared  on  t-,3  sole  of  the  right  foot 
opposite  to  the  head  of  the  first  metatarsal  bone.  Sensation,  which 
had  previously  been  dulled  in  front,  was  now  entirely  lost  throughout 
the  right  leg,  except  in  the  region  supplied  by  the  long  saphenous 
nerve.  Four  days  later  the  pain  ceased,  and  the  eschars  began  to  heal. 
Seven  months  after  the  accident  the  patient  returned  to  the  hospital ; 
there  was  considerable  atrophy  of  the  right  leg,  loss  of  power  in  the 
muscles  that  move  the  foot  and  toes,  and  some  stitfness  at  the  ankle. 
The  movements  of  both  knees  were  normal,  and  the  ligaments  appeared 
to  have  reunited  solidly.  The  patient  limped  in  walking,  but  the  limp 
was  due  solely  to  the  atrophy  of  the  muscles  and  to  the  persistence  on 
the  outer  side  of  the  sole  of  the  right  foot  of  one  of  the  three  ulcera- 
tions that  had  appeared  upon  the  foot  and  heel.  The  trophic  troubles 
1  Le  Dentu  :  Bull,  de  la  Soc.  de  Chirurgie,  1880,  p.  591. 


DISLOCATIONS  OF   THE  KNEE.  871 

were  attributed  to  a  neuritis  of  tlie  popliteal  nerves  occasioned  by  their 
laceration  or  bruising  at  the  time  of  the  accident. 

Paralysis  of  the  muscles  of  the  outer  side  of  the  leg  has  been  ob- 
served in  three  other  cases,  Brand,  Unruh,  and  Poinsot/  in  one  of 
which,  however  (Brand),  the  fibula  had  been  broken  at  its  upper  end. 

Of  the  compound  cases,  several  recovered  with  good  use  of  the 
limb ;  in  others,  amputation  or  excision  of  the  joint  was  done. 

The  prognosis  is  grave  in  the  compound  cases  and  in  those  in  which 
the  artery  has  been  injured,  and  it  is  not  very  favorable  even  in  the 
simpler  ones.  It  must  be  remembered  that  gangrene  mav  delav  its 
appearance  until  the  second  or  even  the  third  week,  and  tliat  even  in 
some  simple  cases  which  have  done  well  for  a  week  or  two  suppuration 
of  the  joint  has  ultimately  occurred.  Even  after  simple  dislocations 
that  have  done  well  there  is  ordinarily  some  limitation  of  the  move- 
ments of  the  joint. 

Treatment.  Reduction  is  easy  by  traction  and  coaptation  of  the  ends 
of  the  bones  ;  ordinarily,  no  more  force  is  required  in  the  traction  than 
an  assistant  can  make  with  his  hands.  Flexion  of  the  knee  to  an 
acute  angle  has  proved  successful.  The  suggestion  that  the  leg  should 
be  hyperextended,  and  the  head  of  the  tibia  then  pressed  directly  down- 
ward, is  a  dangerous  one,  because  of  the  chance  of  injury  to  the  pop- 
liteal vessels. 

The  rule  of  conduct  in  the  presence  of  compound  dislocations,  and 
of  those  in  which  there  is  evidence  of  injury  to  the  popliteal  artery, 
has  been  the  subject  of  recent  discussion.  Several  compound  disloca- 
tions in  which  the  artery  was  intact  have  recovered,  and  even  with  full 
subsequent  use  of  the  joint,  and  I  believe  that  the  conservation  of  the 
limb  under  such  circumstances  should  be  attempted. 

The  same  rule  should  be  followed  in  case  of  arrest  of  pulsation  in 
the  distal  arteries ;  that  is,  the  surgeon  should  wait  until  it  has  become 
evident  that  the  vitality  of  the  limb  is  lost.  If  the  gangrene  is  dry 
little  is  to  be  feared  from  delay,  but  if  the  limb  becomes  swollen  and 
discolored,  with  loss  of  sensation,  indicating  arterial  supply  and  venous 
obstruction,  delay  is  more  dangerous  and  the  formation  of  a  line  of 
demarcation  cannot  be  safely  awaited. 

DISLOCATIONS  BACKWARD. 

These  may  be  complete  or  incomplete  ;  in  IJie  former  the  head  of 
the  tibia  is  displaced  backward  and  u})ward  behind  the  coiulylfs  ;  in 
the  latter  it  still  remains  partly  in  contact  by  its  u])per  siirtace  with 
the  condyles. 

The  common  cause  is  direct  violence  received  upon  the  upper  cud  of 
the  tibia  in  front,  or  upon  the  lower  end  of  the  femur  l)chiu(l,  but  in 
some  cases  the  application  of  the  force  is  more  indirect,  as  when  the 
body  and  thigh  are  forced  forward  while  the  leg  is  held.  In  four  cases 
the  patients  were  caught  in  machinery  and  whirled  around  ;  and  in 
one  case  a  boy,  eleven  years  old,  suffered  a  compound  dislocation  by 
having  his  leg  caught  between  the  spokes  of  a  wagori-whcel. 

'  Poinsot :  Translation  of  Hamilton,  p.  111-'. 
60 


872  DISLOCATIONS. 

Pathology.  The  posterior  ligament  is  torn,  and  usually  one  or  both 
of  the  lateral  ligaments  ;  in  a  case  of  complete  dislocation  with  rupture 
of  the  popliteal  artery  (quoted  by  Malgaigne  ^)  in  which  Kobert  resorted 
to  amputation,  all  the  ligaments  were  intact  except  for  two  rents,  each 
three  centimetres  long,  in  the  posterior  portion  of  the  capsule  through 
which  the  tibia  protruded.  It  seems  likely  that  the  crucial  ligaments, 
or  at  least  the  posterior  one,  must  also  be  ruptured.  The  muscles 
which  bound  the  popliteal  space  have  been  reported  untorn,  but  widely 
infiltrated  with  blood  ;  and  in  other  cases  one  or  both  heads  of  the 
gastrocnemius  and  the  popliteus  have  been  torn.  The  semilunar 
cartilages  may  be  in  part  detached  or  otherwise  injured.  In  a  case 
reported  by  Yast^  a  portion  of  the  tubercle  of  the  tibia  had  been 
torn  oif  by  the  strain  upon  the  ligamentum  patellse.  The  popliteal 
vessels,  both  artery  and  vein,  are  sometimes  completely  torn  across, 
and  sometimes  only  the  inner  and  middle  coats  of  the  artery  are  torn, 
an  injury  the  consequences  of  which  may  easily  be  as  serious  as  those  of 
complete  rupture.  This  injury  is  produced  by  the  forcible  stretching  of 
the  vessels  across  the  sharp  posterior  margin  of  the  head  of  the  tibia. 

The  patella  may  be  drawn  directly  downward  so  as  to  lie  below  its 
normal  position,  or  it  may  be  displaced  outward  to  the  side  of  the  con- 
dyle. In  a  case  reported  by  Fitzgerald  ^  the  patella  was  broken  into 
several  pieces,  and  the  joint  was  opened  at  the  end  of  a  fortnight  by  the 
sloughing  of  the  overlying  skin.  The  injury  was  caused  by  the  fall  of 
a  heavy  case  upon  the  front  of  the  knee.  The  joint  suppurated,  but  the 
patient  recovered  without  entire  less  of  mobility. 

As  complications,  fracture  of  the  femur  above  the  condyles,  Testut,* 
and  fracture  of  the  tibia  just  below  the  knee,  Adams,^  have  been  re- 
ported ;  also  rupture  of  the  tendon  of  the  quadriceps  femoris,  Walsh- 
man,®  Lossen.^ 

Symptoms.  The  leg  is  usually  hyperextended  upon  the  thigh,  the 
antero-posterior  diameter  of  the  knee  notably  increased,  the  head  of 
the  tibia  placed  behind  its  usual  position,  and,  in  the  complete  disloca- 
tions, also  above  the  level  of  the  lower  surface  of  the  condyles  of  the 
femur.  The  leg  may  also  be  deviated  somewhat  to  either  side,  and 
exceptionally  it  may  be  flexed.  The  head  of  the  tibia  can  be  felt  in 
the  popliteal  space,  and  a  marked  depression  exists  below  the  condyles 
of  the  femur  in  front.  The  patella  may  lie  against  the  front  part  of 
the  under  surface  of  the  condyles,  or  may  be  displaced  to  the  outer 
side,  or  rotated  upon  its  axis.  The  amount  of  shortening  is  slight  in 
the  incomplete  form  ;  in  the  complete  form  it  may  be  one  or  two  inches. 

Pressure  upon  or  rupture  of  the  popliteal  artery  is  manifested  by 
absence  of  pulsation  in  the  posterior  tibial  and  dorsalis  pedis  arteries, 
and  may  result  in  gangrene  of  the  limb. 

The  diagnosis  is  not  difficult ;  and  as  reduction  is  usually  easy  the 
prognosis  in  simple,  uncomplicated  cases  is  good ;  but  attention  should 
always  be  paid  to  the  presence  or  absence  of  pulsation  in  the  distal 
branches  of  the  artery,  both  before  and  after  reduction. 

1  Malgaigne :  Loc.  cit.,  p.  945.  ^  y^st :  Bull,  de  la  Soc.  de  Chirurgie,  1877,  p.  688, 

'  Fitzgerald  :  Australian  Medical  Journal,  1882,  p.  554. 

*  Testut:  Bordeaux  Medical,  1874.      «  Adams:  Lancet,  1881,  vol.  ii.  p.  1108. 

*  Walshman  :  Quoted  by  Cooper,  loc.  cit.,  p.  190. 
^  Lossen  :  Deutsche  Chirurgie,  Lief.  65,  p.  131. 


DISLOCATIONS  OF  THE  KNEE.  873 

In  some  reported  cases  in  whieli  the  dislocation  has  remained  unre- 
duced, the  patient  has  had  good  use  of  the  limb.  Two  such  are  the 
cases  of  Bagnall-Oakeley ^  and  Karewski.''  The  former's  patient  Mas 
a  man,  seventy-years  old,  who  had  dislocated  his  left  knee  at  the  age 
of  nine  months ;  he  had  always  made  full  use  of  the  limb,  and  had 
earned  his  living  as  a  brickmaker,  A  false  joint  had  formed  between 
the  femur  and  tibia,  which  permitted  15  degrees  of  flexion.  The  foot 
and  leg  were  normally  developed ;  the  thigh  liad  an  abnormal  anterior 
curvature.  The  patella  could  not  be  recognized,  and  was  thought  to 
have  become  united  with  the  femur.  The  different  prominences  of  the 
lower  end  of  the  femur  were  absolutely  subcutaneous  and  seemed  ready 
to  perforate  the  skin,  but  there  was  no  trace  of  previous  ulceration. 

Fig.  467. 


Posterior  dislocation  of  the  knee. 


Karewski's  patient  was  a  servant  girl,  thirty-two  years  old,  whose 
dislocation  had  existed  for  more  than  sixteen  years.  The  right  limb 
presented  a  typical  dislocation  backward,  and  when  viewed  from  be- 
hind looked  like  a  genu  recurvatum,  while  when  seen  from  in  front 
and  the  side  the  thigh  overhung  the  leg  to  a  certain  extent.  The 
muscles  of  the  calf  were  somewhat  atrophied  ;  the  nerves  and  vessels 
stretched  above  the  tibia  like  tense  cords.  The  growth  of  tlie  bones  had 
been  materially  affected,  the  tibia  being  three  centimetres  shorter  than 

»  Ragnall-Oakelev  :  Lancet,  1882,  vol.  i.  p.  53. 

2  Karewski :  Arch,  fiir  klin.  Chir..  1886.  vol.  xxxiu.  p.  525. 


874  DISLOCATIONS. 

the  other,  and  also  thinner ;  while  the  femur  was  lengthened  by  three 
or  four  centimetres.  The  overriding  of  the  tibia  and  femur  was  four 
centimetres.  Flexion  and  extension  were  normal,  both  actively  and 
passively,  and  although  there  was  much  lateral  mobility  the  functions 
of  the  limb  were  admirably  performed.  Pain  was  felt  only  after  excep- 
tional use. 

In  Lossen's  case,  in  which  reduction  was  attempted  at  the  end  of 
six  weeks  and  failed,  the  patient  finally  walked  well ;  extension  was 
complete ;  flexion  to  a  right  angle.  The  rupture  of  the  external  lat- 
eral ligament  resulted  in  the  production  of  a  genu  varum. 

Treatment,  Reduction,  which  is  usually  easy,  has  been  effected  by 
traction  with  coaptative  pressure  upon  the  adjoining  ends  of  the  femur 
and  tibia  and  flexion  of  the  knee  and  hip.  In  some  cases  flexion 
alone  has  been  sufficient. 

Spence^  successfully  treated  an  irreducible  dislocation  by  open 
arthrotoray.  The  patient  was  a  man,  sixty  years  old,  who  had  I'eceived 
the  dislocation  March  15,  1876,  two  days  before  admission  to  the  hos- 
pital. After  a  failure  to  reduce  under  anaesthesia,  continuous  traction 
with  a  weight  of  sixteen  pounds  was  made  for  three  days,  and  then  a 
second  unsuccessful  attempt  Mas  made.  March  22d,  traction  with 
pulleys  having  also  failed,  the  joint  was  opened  by  a  curved  incision 
below  the  patella;  it  was  found  filled  with  clots,  the  internal  lateral 
ligament  broken,  and  the  posterior  part  of  the  internal  semilunar  car- 
tilage displaced.  After  division  of  the  external  lateral  ligament  and 
the  tendons  of  the  hamstring  muscles,  the  dislocation  was  easily 
reduced.  The  wound  was  drained  and  dressed  antiseptically,  the  limb 
placed  on  a  long  posterior  splint,  and  continuous  traction  made  with  a 
weight  of  eight  pounds.  As  the  lower  end  of  the  femur  tended  to 
project  anteriorly,  pressure  was  made  upon  it  in  front.  The  traction 
was  maintained  until  Jmie  15th,  and  when  the  patient  was  last  seen, 
September  13th,  the  limb  promised  to  be  very  useful. 

In  compound  dislocations,  and  in  those  complicated  by  injury  to  the 
main  vessels  and  nerves,  the  principles  of  treatment  are  the  same  as  in 
dislocations  forward. 

LATERAL    DISLOCATIONS, 

Lateral  dislocation,  more  rare  than  either  of  the  preceding  varieties, 
may  be  outward  or  inward,  complete  or  incomplete,  simple  or  com- 
pound. The  outward  form  is  more  common  than  the  inward.  The 
term  subluxation  has  been  applied  to  those  cases  in  which  the  displace- 
ment is  slight, 

1.  Outward  Dislocations, 

Of  the  complete  form  of  this  dislocation  Malgaigne  could  find  only 
one  recorded  case,  and  that  a  doubtful  one ;  but,  since  the  publication 
of  his  work,  von  Pitha^  has  reported  two  cases  in  which  the  disloca- 
tion was  nearly,  perhaps  quite,  complete;  Hughes^  has  since  published 
a  third,  and   McKenzie  *  a  fourth.     Von   Pitha's  first  patient  was  a 

^  Spence :  Lancet,  1876,  vol.  ii.  p.  534. 

^  Pitha  and  Billroth  :  Chirurgie,  vol.  iv.,  part  2,  B.,  p.  258. 

3  Hughes:  Lancet,  1880,  vol.  ii.  p.  974. 

*  McKenzie  :  Canadian  Practitioner,  January,  1893, 


PLATE  XXXVIII 


Fig.  1 


Fig.  2 


Out-ward,  Dislocation  of  the  Knee. 


DISLOCATIONS  OF  THE  KNEE.  875 

young  woman  who,  while  carrying  a  heavy  basket  on  her  back,  sud- 
denly doubled  up  under  it.  The  right  tibia  was  so  completely  dislo- 
cated outward  that  its  entire  upper  articular  surface  stood  out  free,  so 
that  von  Pitha  could  easily  lay  four  fingers  upon  it.  The  skin  was 
tightly  and  smoothly  stretched  over  the  articular  surface,  and  was  con- 
tinuous at  a  sharp  angle  with  that  of  the  side  of  the  thigh  ;  the  edge 
of  the  tibia  threatened  to  cut  through  the  tense,  thin  skin,  and  in  like 
manner  the  internal  condyle  of  the  femur  projected  abruptly  over  the 
leg.  The  patella  was  displaced  outward,  and  was  placed  obliquely, 
almost  transversely.  Reduction  was  extraordinarily  easy.  The  reac- 
tion was  so  slight  that  the  patient  left  the  hospital  on  the  next  day. 

His  second  patient  was  a  robust  young  man  who  received  his  injury 
by  springing  to  the  sidewalk  from  an  overturning  wagon;  the  symp- 
toms were  similar,  reduction  easy.  Hughes's  and  McKenzie's  cases 
were  also  similar  in  appearance  and  ease  of  reduction.  Hughes's 
patient  died  promptly;  McKenzie's  recovered. 

In  the  incomplete  form  only  a  part  of  the  head  of  the  tibia,  usually  all  the 
outer  half,  projects  beyond  the  side  of  the  external  condyle  of  the  femur. 

The  commonest  cause  is  outward  flexion  of  the  knee,  abduction,  pro- 
duced by  a  fall  upon  the  foot  or  by  the  pressure  of  a  heavy  weight  upon 
the  posterior,  or  by  a  blow  upon  the  outer,  side  of  the  knee  ;  in  the  lat- 
ter case  the  blow  is  probably  received  upon  the  lower  end  of  the  femur 
and  not  upon  the  tibia.  A  rarer  cause  is  direct  violence  acting  trans- 
versely upon  the  outer  side  of  the  lower  end  of  the  femur  or  the  inner 
side  of  the  head  of  the  tibia  without  causing  lateral  inflection  (Annan- 
dale).  The  mode  of  production  appears  to  be  rupture  of  the  internal 
lateral  and  perhaps  of  the  crucial  ligaments  by  abduction  of  the  leg, 
followed  by  the  lateral  gliding  of  the  articular  surfaces. 

The  only  reports  of  direct  examination  of  the  injured  joint  are  fur- 
nished by  Hargrave^  and  Bonn,  quoted  by  Malgaigne,  and  by  Wells.^ 
Hargrave's  patient  died  on  the  fifty -third  day,  after  suppuration  of  the 
joint ;  the  internal  lateral  ligament  was  completely  ruptured,  the  exter- 
nal partly  torn ;  the  anterior  crucial  torn  across,  the  posterior  crucial 
and  the  ligaments  of  the  patella  intact.  Bonn's  was  an  old  unreduced  dis- 
location ;  he  says  all  the  ligaments  were  intact  and  that  the  external  con- 
dyle of  the  femur  rested  upon  the  crest  of  the  tibia.  In  Well's  case  a  large 
scale  of  bone  was  torn  from  the  inner  side  of  the  internal  condyle ;  the 
patient  died  on  the  fourth  day  in  consequence  of  gangrene  of  the  limb. 

In  a  personal  case  (1909),  Plate  XXXVIII,  the  rent  in  the  capsule 
extended  transversely  upward  and  backward,  on  the  inner  side,  involv- 
ing the  lower  portion  of  the  vastus  internus  and  overlying  fascia ; 
the  internal  condyle  had  passed  through  the  rent  (evidently  by  abduc- 
tion of  the  leg  while  the  knee  was  partly  flexed) ;  and  the  upper  side 
of  the  rent  was  tightly  lodged  in  the  intercondylar  notch.  The  inter- 
nal lateral  ligament  was  torn  away  from  the  femur,  and  the  crucial 
ligaments  apparently  were  torn,  certainly  in  part.  After  having 
opened  the  joint  by  a  longitudinal  incision  along  the  prominent  part 
of  the  internal  condyle  I  was  able,  with  some  difficulty,  to  lift  the 

•  Hargrave  :  Dublin  Quarterly  Journal  Med.  Sci.,  1850,  vol.  ix.  p.  473. 
■•*  Wel&  :  American  Journal  of  the  Medical  Sciences,  1832,  vol.  x.  p.  25. 


876  DISLOCATIONS. 

tense  engaged  portion  of  the  capsnle  ont  of  the  intercondylar  notch  and 
shp  it  back  over  the  condyle^  reducing  the  dislocation. 

Instead  of  being  directly  outward  the  displacement  may  also  be 
somewhat  backward  or  forward.  When  compound,  the  wound  has 
always  been  on  the  inside.  In  one  compound  case,  Notta,^  the  pop- 
liteal artery  was  ruptured  and  the  patient  died  after  amputation. 

Symptoms.  The  symptoms  are  more  or  less  marked  in  accordance 
with  the  degree  of  the  displacement ;  the  internal  condyle  of  the  femur 
projects  more  or  less  markedly  on  the  inner  side,  and  the  outer  part  of 
the  head  of  the  tibia  on  the  outer  side  ;  and  the  greater  the  displace- 
ment the  more  likely,  according  to  Malgaigne,  is  it  that  the  outer  part 
of  the  tibia  will  be  rotated  backward.  The  displacement  outward  of 
the  patella  shows  corresponding  variations  in  degree  ;  it  may  be  simply 
inclined,  so  that  its  vertical  axis  is  directed  downward  and  outward, 
or  it  may  be  carried  to  the  outer  side  of  the  external  condyle. 

The  leg  may  be  flexed  or  extended,  and  is  usually  adducted,  but  may 
be  widely  abducted  ;  voluntary  movements  are  generally  impossible. 

Prognosis.  The  prognosis  does  not  differ  materially  from  that  in  the 
two  preceding  forms ;  but  it  is  worthy  of  note  that  in  a  case  seen  six 
years  after  the  accident  by  Desormeaux  (quoted  by  Spillman)  the  leg 
was  permanently  abducted  45  degrees,  presumably  the  consequence  of 
failure  of  repair  of  the  internal  lateral  ligament.  In  another,  reported 
by  Morgan, 2  in  which  the  dislocation  had  remained  unreduced  for  three 
and  a  half  years,  the  limb  could  be  flexed  to  a  right  angle  but  could 
not  be  voluntarily  extended,  so  that  the  patient  fell  whenever  the  leg 
became  at  all  bent  while  he  was  standing  upon  it. 

Treatment.  Reduction,  generally  very  easy,  is  effected  by  traction 
and  direct  coaptative  pressure  upon  the  ends  of  the  bones.  It  is  very 
important  that  the  limb  should  be  immobilized  for  a  long  time  after 
reduction  in  order  that  the  torn  ligaments  may  solidly  reunite.  Prob- 
ably it  would  be  well  to  keep  the  limb  for  three  or  four  months  in  a 
firm  dressing  which  would  keep  it  extended  and  prevent  lateral  bend- 
ing. Massage  and  passive  motion  might  be  systematically  employed 
during  much  of  this  time  if  loss  of  normal  mobility  were  feared. 

In  a  case  reported  by  Braun^  of  incomplete  outward  dislocation 
which  proved  irreducible  arthrotomy  was  clone.  The  patient  was  a 
man  forty-four  years  old ;  the  leg  was  rotated  inward  and  abducted  at 
an  angle  of  145  degrees ;  the  internal  condyle  of  the  femur  was  promi- 
nent, and  a  small  movable  piece  of  bone  could  be  felt  below  its  inner 
side.  "  A  curved  incision  eight  centimetres  long  was  made  parallel  to 
the  internal  condyle."  The  small  piece  of  bone  proved  to  be  the 
detached  internal  tuberosity.  The  rent  in  the  capsule  was  closely 
filled  by  the  internal  condyle ;  it  was  slightly  enlarged  with  the  knife, 
and  then  reduction  was  easily  made.  The  patient  made  a  slow  recov- 
ery ;  the  joint  remained  stiff. 

The  treatment  of  compound  dislocations  and  of  those  in  which  the 
artery  has  been  torn  is  the  same  as  in  forward  dislocations  (q.  v.). 

1  Notta :  Annales  Med.  du  Calvados,  1876,  quoted  by  Poinsot. 

2  Morgan  :  Lancet,  1825-2fi,  vol.  ix.  p.  843. 

3  Braun :  Deutsche  med.  Wochenschrift,  1882,  p.  291. 


DISLOCATIONS  OF  THE  KNEE.  877 

2.  Inward  Dislocations. 

These  also  may  be  complete  or  incomplete,  simple  or  compouiul. 
Of  the  complete  form  there  are  only  two  cases  on  record,  Miller  and 
Hoifman,^  and  Galli,  both  quoted  by  Malo^aigne.  The  first  was  a 
man  twenty-eight  years  old  who  while  getting  into  a  carriage  caught 
his  leg  between  the  spokes  of  the  wheel  and  could  not  free  it  before 
the  horses  started.  The  femur  was  completely  separated  from  the  til)ia 
and  projected  outward  and  downward,  the  external  condyle  presenting 
through  a  wound  in  the  skin  three  inches  long.  Through  this  wound 
the  joint  and  the  uninjured  popliteal  artery  could  be  seen,  lleduction 
was  made  at  once  without  difficulty  ;  recovery. 

Galli's  patient,  a  very  muscular  young  man,  Avas  thrown  from  a 
horse,  striking  upon  the  right  foot  with  the  limb  abducted.  The  lower 
end  of  the  femur  had  almost  entirely  passed  through  the  soft  parts  on 
the  outer  side  ;  the  ligamentum  patellse  was  ruptured.  Reduction  was 
made  and  the  patient  recovered. 

The  causes  of  the  incomplete  form  are  similar  to  those  of  the  out- 
ward dislocations  :  lateral  flexion  of  the  knee  or  a  blow  upon  the  outer 
side  of  the  tibia  or  on  the  inner  side  of  the  condyle  of  the  femur. 

In  a  case  quoted  from  Cooper  by  Malgaigne^  in  which  there  was  also 
rotation  inward  of  the  tibia,  the  soft  parts  covering  the  external  con- 
dyle of  the  femur  behind  and  externally  had  been  ruptured.  The 
limb  was  amputated,  and  dissection  showed  a  large  rent  in  the  vastus 
externus  immediately  above  its  insertion  upon  the  patella ;  posteriorly 
the  capsule  and  gastrocnemius  were  torn  ;  the  lateral  and  crucial  liga- 
ments were  intact. 

The  symptoms  of  the  incomplete  form  are  the  projection  of  the  head 
of  the  tibia  on  the  inner  side  and  of  the  external  condyle  of  the  femur 
on  the  outer  side.  The  leg  may  be  inclined  outward  or  inward,  rotated 
inward,  and  more  or  less  flexed. 

Reduction  appears  always  to  have  been  effected  without  much  difii- 
culty  by  traction  and  coaptative  pressure ;  and  the  only  special  feature 
in  the  prognosis  arises  from  the  rupture  of  the  internal  lateral  ligament, 
for  if  its  repair  is  not  thorough,  or  if  the  limb  is  prematurely  used, 
the  leg  tends  to  deviate  outward  (knock-knee)  under  the  weight  of  the 
body.  It  would,  therefore,  be  advisable  to  support  the  joint  for  a  long 
time  by  means  of  a  brace. 

ANTEROLATERAL  DISLOCATIONS. 

Antero-lateral  dislocations  constituted  in  Malgaigne's  classification 
a  separate  class  of  very  rare  occurrence.  Of  the  forward  and  outward 
form  he  found  only  one  recorded  example  and  that  a  doubtful  one.  In 
the  very  rare  examples  of  dislocation  forward  and  inward  no  special 
features  appear;  and  the  same  may  be  said  of  the  equally  rare  dis- 
locations backward  and  ouhcard.  They  may,  therefore,  be  treated  as 
belonging  to  the  forward  and  backward  dislocations  resi)ecti\'ely. 

1  Miller  and  Hoffman:  London  Medical  Repository,  1S25,  p.  34G. 

2  Cooper;  Quoted  by  Malgaigne,  loc.  cit.,  p.  9G0. 


378  DISLOCATIONS. 

DISLOCATIONS   BY  ROTATION. 

In  this  form  the  dislocation  is  characterized  by  a  rotation  of  tlie  leg 
about  its  longitudinal  axis  or  about  a  parallel  axis  passing  through  the 
centre  of  one  of  the  condylar  surfaces  of  the  tibia ;  in  the  former  case 
both  condylar  surfaces  are  displaced  from  their  corresponding  con- 
dyles, and  the  dislocation  is  said  to  be  complete ;  in  the  latter  only  one 
of  them  is  thus  displaced,  an  1  the  dislocation  is  said  to  be  incomplete. 
The  descriptive  terms  outward  and  inward  are  used,  as  in  normal  rota- 
tion of  the  leg,  according  to  the  direction  in  which  the  toes  are  turned. 

Outward  Rotation. 

The  first  recorded  case  is  one  reported  by  Dubreuil  and  Martelliere/ 
at  the  time  internes  in  Malgaigne's  service.  The  patient  was  a  woman, 
who  while  walking  in  the  street  was  struck  upon  the  back  of  the  leg 
by  the  end  of  a  ladder  carried  upon  a  cart.  She  was  knocked  down 
by  the  blow,  her  foot  caught  between  the  rounds  of  the  ladder,  and  she 
was  dragged  a  few  feet.  When  brought  to  the  hospital,  the  leg  was  com- 
pletely extended  and  rotated  outward,  so  that  the  internal  tuberosity 
was  in  front,  below  the  trochlea  of  the  femur,  the  external  tuberosity 
and  the  head  of  the  fibula  behind  in  the  intercondylar  notch.  The 
patella  lay  upon  the  outer  side  of  the  external  condyle.  There  was 
also  a  compound  fracture  of  both  bones  of  the  leg  in  Ihe  middle 
third.  Reduction  was  easily  made  two  hours  after  the  accident  by 
slight  traction  upon  the  upper  portion  of  the  leg  followed  by  inward 
rotation.  Recovery  took  place,  but  the  joint  was  not  firm,  and  nine- 
teen months  after  the  accident  the  patient  could  not  take  a  step  with- 
out crutches. 

By  experiment  upon  the  cadaver  the  reporters  found  they  could 
produce  the  dislocation  by  forcible  outward  rotation  of  the  leg  con- 
tinued until  the  ligaments  were  felt  to  yield.  The  lateral  ligaments 
were  then  found  to  be  ruptured  or  torn  from  one  or  the  other  insertion ; 
the  capsule,  the  fascia  on  the  outer  side,  and  some  muscular  bundles 
were  torn,  the  semilunar  cartilages  loosened  or  displaced.  The  crucial 
ligaments  were  not  torn  but  lay  parallel  with  each  other  in  the  trans- 
verse vertical  plane  passing  through  their  upper  insertions.  In  one 
experiment  the  tendon  of  the  biceps  was  torn  away  from  the  head  of 
the  fibula.  The  tendon  of  the  semi-membranosus  was  wrapped  under 
the  internal  condyle  and  prevented  full  extension  of  the  leg. 

Sulzenbacher^  reported  another  case  and  repeated  and  confirmed 
these  experiments.  His  patient  was  a  young  Italian  laborer,  and  the 
dislocation  was  caused  by  forcible  outward  rotation  of  the  leg  followed 
by  hyperextension  of  the  knee.  The  leg  was  extended,  neither 
abducted  nor  adducted,  and  so  far  rotated  outward  that  as  the  patient 
lay  on  his  back  the  outer  border  of  the  foot  rested  on  the  bed.  Beside 
the  rotation  there  was  displacement  backward  and  outward  of  the 
upper  end  of  the  tibia.  Notwithstanding  the  swelling  there  was  a 
distinct  projection  of  the  condyles,  and  the  soft  parts  below  them  were 

1  Dubreuil  and  MartelliSre :  Arch.  gen.  de  Med.,  1852,  vol.  xxx.  pp.  150  and  288. 
^  Sulzenbacher :  Wiener  med.  Presse.  1880,  vol.  xxi.  p.  272. 


DISLOCATIONS  OF  THE  KNEE.  879 

deeply  depressible.  Below  the  iuternal  condyle  was  a  movable  piece 
of  bone  as  large  as  a  bean.  The  upper  end  of  the  tibia  could  be  felt 
in  the  hollow  of  the  knee  projecting  backward  and  outward  and  so 
rotated  that  the  outer  surface  and  the  head  of  the  fibula  lay  furthest 
back  and  the  outer  articular  surface  could  be  felt  tli rough  the  soft 
parts.  The  inner  articular  surface  lay  in  the  depths  of  tiie  popliteal 
fossa,  the  patella  laterally,  so  that  it  rested  snugly  on  the  outer  sur- 
face of  the  external  condyle,  its  anterior  surface  being  directed  outward. 
There  was  one  inch  shortening,  and  the  antero-posterior  diameter  of 
the  joint  was  notably  increased. 

Reduction  was  easily  effected  by  flexing  the  leg  a  little,  then  rotating 
it  inward  and  pressing  the  head  forward,  and  finally  extending. 

There  was  a  tendency  during  the  first  fortnight  to  subluxation  back- 
ward and  outward  ;  a  gypsum  dressing  was  worn  during  the  second 
fortnight,  and  on  its  removal  the  tendency  had  ceased.  At  the  end  of 
six  weeks  the  patient  could  walk  with  a  cane. 

The  case  differs  from  the  preceding  one  in  the  additional  backward 
and  outward  displacement  of  the  rotated  leg. 

Experimenting  on  the  cadaver,  Sulzenbacher  found  that  by  rotating 
the  leg  outward  45  degrees  he  got  an  incomplete  dislocation,  accompa- 
nied by  the  appearance  of  a  small  fragment  of  bone  under  the  internal 
condyle  similar  to  that  observed  in  his  case,  and  that  then  by  hyper- 
extension  he  could  make  the  dislocation  complete  and  exactly  like  that 
of  his  patient.  The  lesions  found  on  dissection  differed  from  those 
noted  by  Dubreuil  and  Martelliere  in  this,  that  the  crucial  ligaments 
were  ruptured  and  the  external  lateral  ligament  untorn.  The  small 
movable  piece  of  bone  proved  to  be  the  part  of  the  internal  condyle 
to  which  the  internal  lateral  ligament  was  attached. 

In  a  case  reported  by  Boursier^  still  another  variety  is  shown,  the 
rotation  taking  place  about  the  internal  condyle  as  a  centre.  The 
patient,  while  standing  with  the  outer  side  of  his  right  leg  resting 
against  the  cross-bar  of  a  pair  of  skids  by  which  he  was  unloading  a 
large  cask,  was  overthrown  by  the  rapid  descent  of  the  cask  which 
struck  against  the  inner  side  of  the  right  knee.  The  pain  was  very 
severe,  and  when  raised  by  his  companions  he  was  unable  to  stand. 
The  knee  appeared  a  little  enlarged  transversely ;  the  external  condyle 
overlapped  the  corresponding  articular  surface  of  the  tibia,  forming  a 
rather  large,  hard,  rounded  prominence.  The  patella,  firmly  fixed  ujion 
this  condyle,  was  placed  obliquely,  its  external  border  tending  to  turn 
forward.  The  relations  of  the  internal  condyle  and  inner  surface  of 
the  tibia  were  normal.  Palpation  was  painful  along  the  interarticular 
line,  especially  at  the  outer  side.  Voluntary  movement  was  impossible. 
Passively,  flexion  could  be  made  nearly  to  a  right  angle,  but  was  very 
painful ;  the  limb  could  not  be  completely  extended,  and  there  was  no 
rotation.  No  sign  of  fracture.  Reduction  was  easily  made  under 
anesthesia  by  slight  traction  and  inward  rotation  of  the  leg.  The 
patient  recovered  completely. 

Another  case  has  been  reported  by  Mazel,^and  Malgaigne  quotes  the 

1  Boursier :  Journ.  de  Med.  de  Bourdeaux,  1882-83,  vol.  xii.  p..'225,  quolcd  by  ruiiisut. 
'^  Mazel :  Montpellier  Medical,  1863.  vol.  x.  p.  76. 


DISLOCATIONS. 

accounts  of  two  specimens  of  old  unreduced  dislocations  given  by  God- 
man  and  Petrequin.  Of  the  former  it  is  only  said  that  "  the  leg  has  un- 
dergone complete  outward  rotation,  so  that  the  foot  points  directly  out- 
ward, the  heel  corresponding  to  the  hollow  of  the  other  foot,  and  the 
articulation  of  the  knee  crossing  its  natural  position  at  right  angles." 
Still  another  variety,  displacement  forward  of  the  inner  side  of  the 
head,  the  outer  remaining  in  place,  has  been  recently  reported  by 
H^naff.^  "  A  sailor,  thirty-three  years  old,  while  squatting  with  his 
heels  together,  thighs  abducted,  and  knees  flexed,  was  struck  upon  the 
inner  side  of  the  head  of  the  left  tibia  by  an  iron  ring  through  which 
a  hawser  had  begun  to  run  rapidly.  When  brought  to  the  hospital 
the  leg  was  partly  flexed  and  not  deviated  to  either  side ;  flexion  and 
extension  were  limited,  abnormal  lateral  movements  very  free.  The 
relations  of  the  external  condyle  and  tibia  were  unchanged  ;  the  inner 
side  of  the  head  of  the  tibia  was  displaced  forward,  and  the  internal 
condyle  was  prominent  posteriorly.  The  patella  was  inclined  so  that 
its  anterior  face  looked  forward  and  inward,  its  inner  border  rested  on 
the  inner  condylar  surface  of  the  tibia,  and  its  outer  border  and  point 
raised  the  skin,  the  point  being  nearly  in  the  median  line.  Reduction 
was  easily  efl^ected  by  traction  and  internal  rotation,  and  the  patient 
made  a  complete  recovery." 

Inward  Rotation. 

Of  this  the  only  recorded  instance  is  one  reported  by  Paris,  and 
quoted  by  Malgaigne.  "  The  internal  condyle  of  the  tibia  had  slipped 
behind  the  corresponding  condyle  of  the  femur.  The  limb  was  short- 
ened five  or  six  centimetres,  and  the  leg  and  thigh  formed  an  arc  of  a 
circle."  Malgaigne  supposes  this  to  have  been  an  incomplete  disloca- 
tion by  rotation  inward,  and  explains  the  alleged  shortening  as  an 
error  of  observation.  He  mentions  in  connection  with  it  a  singular 
displacement  which  he  had  himself  seen,  and  which  he  thought 
belonged  to  this  class  more  than  to  any  other.  When  seen  by  him  it 
had  existed  five  years.  Although  the  patient  limped,  he  flexed  and 
extended  the  leg  quite  freely.  In  extension  tlie  internal  condyle  pro- 
jected very  slightly  forward  and  inward,  and  the  relations  of  the  exter- 
nal condyle  were  normal.  In  marked  flexion  the  internal  condyle 
Drojected  considerably  forward  and  inward,  the  inward  projection 
being  more  tiian  two  centimetres,  and  the  external  condyle  projected 
slightly   forward. 

1  Henaif :  Th^se  de  Paris,  1883,  No.  277. 


DISLOCATIONS  OF  THE  KNEE.  881 

DISLOCATION  OF    THE  SEMILUNAR  CARTILAGES. 

"Subluxation   of  the   Knee."       Key's    "Internal   Derangement 

of   the    Knee." 

A  certain  group  of  symptoms  at  the  knee,  occasioned  usually  by 
slight  violence,  such  as  the  twisting  of  the  leg,  or  marked  flexion  of 
the  joint,  and  having  a  decided  tendency  to  recur,  to  which  attentiijn 
was  first  permanently  called  by  Hey  ^  nearly  one  hundred  years  ago, 
have  only  of  late  been  clearly  connected  with  displacement  of  a  semi- 
lunar cartilage  as  the  cause.  In  many  cases  the  symptoms  are  identical 
with  those  caused  by  a  floating  cartilage  in  the  joint,  and  many  of  the 
reported  cases,  especially  the  earlier  ones,  were  probably  of  this  char- 
acter. Hey  reported  five  cases,  and  said  he  had  seen  many  others ; 
the  difficulty  always  occurred  suddenly,  sometimes  without  recognizable 
cause  during  ordinary  use  of  the  limb,  the  joint  becoming  "locked" 
in  the  position  of  slight  flexion,  with  more  or  less  pain,  the  patient 
being  unable  to  bring  his  heel  to  the  ground  and  walking  on  the  toes, 
but  the  joint  could  always  be  freely  moved  passively.  It  was  always 
relieved  by  gradual  passive  extension  of  the  limb  followed  by  sudden 
full  flexion. 

In  1731  Bassius  (quoted  by  Malgaigne)  reported  the  first  case,  but 
it  differs  notably  from  all  that  have  since  been  reported,  for  the  exter- 
nal semilunar  cartilage  had  become  much  hypertrophied  in  conse- 
quence of  an  arthritis,  and  formed  a  projection  on  the  outer  side  as 
large  as  the  thumb ;  it  could  be  pressed  into  place  with  crepitus,  and 
became  displaced  when  the  pressure  was  removed. 

In  some  cases  a  distinct  projection  had  been  noticed  in  front,  formed 
by  one  or  the  other  cartilage,  which  could  be  made  to  disappear  by 
pressure  or  by  flexing  and  extending  the  joint,  and  with  the  disappear- 
ance of  the  projection  the  symptoms  ceased.  It  was  upon  these  few 
cases  of  recognizable  projection  and  upon  the  sensation  sometimes  felt 
of  a  distinct  slipping  or  jar  in  the  joint  while  it  is  moved,  that  the 
theory  of  displacement  of  the  cartilage  rested,  it  being  supposed  that  it 
slipped  forward  upon  the  head  of  the  tibia  so  that  its  thicker  posterior 
margin  lay  between  the  condyle  and  tibia  at  or  in  front  of  the  point 
where  they  come  most  nearly  into  contact  or  actually  touch. 

The  only  pathological  data  came  from  chance  examination  of  a  few 
knees  without  history  ;  thus  in  two  specimens  described  by  Reid^  and 
Godlee,^  the  rupture  of  the  attachments  had  taken  ])lace  along  the 
periphery  of  the  cartilage,  and  it  had  lodged  vertically  in  the  inter- 
condylar notch  alongside  the  spine  of  the  tibia  and  the  posterior  crucial 
ligament.  In  each  the  opposing  articular  cartilage  on  the  condyle  and 
tibia  showed  some  roughening.  Reid's  patient  died  in  the  hospital, 
and  during  his  stay  there  had  made  no  complaint  of  the  knee,  and  had 
not  been  observed  to  limp. 

In  another,   Fergusson  (quoted   by  Marsh)  found  in  a  disseeting- 

^  Hey :  Observations  in  Surgery,  Am.  ed  ,  1805,  p.  208. 
'^  Reid:  Edinburgh  Medical  and  Surgical  Journal,  1334,  vol.  xlii.  p.  377. 
»  Godlee  :   Transactions  of  the  Pathological  Society  ol"  London,  1879-80,  vol.  xxxi. 
p.  240. 


882  DISLOCATIONS. 

room  subject  "  that  one  of  the  semihmar  cartilages  had  been  torn  from 
the  tibia  throughout  its  whole  length,  except  at  its  ends,  so  that  in 
flexion  and  extension  is  sometimes  slipped  behind  the  articular  sur- 
faces. The  cartilage  was  flattened  in  its  outer  margin,  and  when  it 
passed  behind  the  condyle  of  the  femur,  seemed  to  fit  to  the  articular 
surfaces  as  accurately  as  the  internal  ca\dty  does  in  the  natural  condi- 
tion of  the  parts." 

Marsh  ^  gives  a  fourth  case  :  "  In  a  subject  lately  in  the  dissecting- 
room  at  St.  Bartholomew's  Hospital,  a  considerable  piece  had  become 
partially  detached  from  the  rim  of  the  internal  cartilage,  and  was  found 
standing  up  like  a  tongue,  so  that  it  would  have  had  the  eifect,  when 
it  was  nipped  between  the  bones  (as  it  was  in  certain  positions  of  the 
joint),  of  locking  the  knee.  A  deep  groove  on  the  cartilaginous  edge 
of  the  femur  had  been  formed  by  long  pressure,  for  its  accommodation." 

Since  1881,  when  Nicoladoni^  exposing  what  he  thought  to  be  a 
floating  cartilage  found  it  was  the  displaced  meniscus,  and  1885,  when 
Annandale^  reported  four  cases  diagnosticated  as  displacement  and 
formally  treated  by  arthrotomy,  the  patiiology  of  the  condition  has 
been  made  clear  by  many  *  direct  examinations  through  incisions,  and 
very  recently  Tenney  ^  in  a  most  interesting  article  has  given  the 
results  of  examination  of  150  joints  of  cadavers  showing  the  various 
forms  of  change  in  the  cartilages  and  fringes.  The  meniscus  most 
frequently  displaced  is  the  internal — 45  internal  and  17  external  in  62 
cases  collected  by  Schlatter.^  The  detachment  may  be  of  the  anterior 
end  or  of  a  variable  length  of  the  periphery,  or  of  a  piece  from  the  free 
border  of  the  cartilage.  The  meniscus  may  be  displaced  into  the  inter- 
condyloid  notch,  or  backward  into  the  joint,  or  slightly  forward  in  front, 
or  the  detached  end  may  escape  forward  or  backward  and  to  the  side. 
Partial  detachment  of  a  piece  from  the  upper  border  seems  to  be  not 
infrequent;  one  such  case  is  quoted  above;  Croft'  reports  another;  I 
have  seen  one. 

Symptoms.  In  most  cases  the  patient  feels  that  the  knee  has  sud- 
denly become  locked,  with  more  or  less  pain  and  loss  of  power  over 
the  limb,  which  he  can  neither  flex  nor  extend.  Then,  after  a  time, 
and  as  the  result  of  manipulation  of  the  joint  or  of  the  limb,  he  feels 
that  all  is  right  again,  and  walks  as  well  as  before.  In  others  the 
joint  has  remained  stiff  and  slightly  flexed  for  weeks,  or  even  years 
(Smith's*),  and  has  been  cured  by  pressure  with  the  thumb  upon  the 
projecting  semilunar  cartilage,  while  the  joint  was  repeatedly  flexed 
and  extended.  In  some  cases  the  cartilage,  usually  the  internal,  can 
be  distinctly  felt  to  project  in  front ;  in  others  it  appears  to  be  absent, 
and  in  others  again  there  is  no  recognizable  change  ;  usually  there  is 
pain  on  pressure  at  the  edge  of  +he  tibia  beside  the  ligamentum  patella. 

Le  Fort,"  himself  the  subject  of  the  affection,  felt  that  something 

1  Marsli  •  Diseases  of  Joints,  p.  199. 

"^  Nicoladoni  :  Arch,  fiir  klin.  Cliir.,  1881-82,  vol.  xxvii.  p.  667. 

^  Annandale :  British  Medical  Journal,  1885,  vol.  i.  p.  77S,  and  1887,  vol.  i.  p.  319. 

*  Two  hundred  and  sixty-two  between  1893  and  1910  at  St.  Bartholomew's  Hospital, 
according  to  D'Arcy  Power  (Brit.  Med.  Jour.,  Jan.  14,  1911). 

*  Tenney:  Annals  of  Surgery,  July,  1904,  p,  1. 

^  Schlatter:  Beitrage  zur  klin.  Chir.,  vol.  xli.  part  II. 
■J  Croft:  British  Medical  Journal,  March  19,  1888. 

8  Smith  :  Transactions  of  the  Clinical  Society  of  London,  1884,  vol.  xvii.  p.  123. 

9  Le  Fort :  Bull,  de  la  Soc.  Chirurgie,  1879,  p.  578. 


DISLOCATIONS   OF  THE  KNEE.  883 

became  displaced  forward  iu  the  knee  whenever  the  joint  was  mark- 
edly flexed,  and  returned  to  its  place  with  a  distinct  snap  and  with  pain 
when  the  limb  was  straightened. 

In  a  case  seen  by  Agnew/  a  lady,  while  playing  with  a  kitten  on  the 
floor,  suddenly  found  that  both  knees  had  become  locked,  so  that  she 
was  unable  to  rise. 

As  in  these  last  instances,  flexion  of  the  knee  beyond  a  certain  point 
is,  in  some  cases,  sure  to  produce  the  condition,  and  this  is  then 
relieved  by  extension ;  but  in  most  the  occurrence  is  not  so  uniform  in 
its  mode  of  production,  and  the  commonest  cause  appears  to  be  out- 
ward rotation  of  the  leg  with  slight  flexion. 

Treatment.  Immediate  relief  can  generally  be  obtained  by  gentle 
movements,  flexion,  adduction,  and  rotation  of  the  leg,  coml)ined  with 
pressure  on  the  cartilage  if  it  can  be  felt  to  project.  Patients  some- 
times learn  to  do  this  readily  for  themselves. 

The  after-treatment  may  require  permanent  pressure  by  a  pad  at  the 
point  at  which  the  cartilage  tends  to  protrude,  or  the  wearing  of  a 
brace  that  will  limit  the  movements  of  the  joint.  Marsh,  who  has 
treated  many  cases,  recommends  a  clamp  (Fig.  468)  "  which  consists 
of  a  steel  band  passing  across  the  back  of  the  joint,  and  ending  later- 
ally in  two  plates,  which  clasp  the  joint  and  skirt  the  edges  of  the 
patella,  a  pad  being  placed  beneath 

the  plate,  should  either  of  the  semi-  Fig.  468. 

lunar  cartilages  be  felt  to  project." 
Prolonged  immobilization  of  the 
limb  in  a  fixed  dressing  has  been 
used  in  a  number  of  cases  and 
seemed  to  diminish  the  tendency 
to  recurrence. 

Operative  measures  to  effect  a 
radical  cure  have  for  their  object 
either  to  remove  the  displaced  car- 
tilage or  to  restore  it  to  place  and 
secure  it  there  by  sutures..  The 
reported    results    have   been    uni- 

"  "  -  -        -  v^mmp    i;U    pj 

lunar  cartilage. 

meniscus    appearing   to    create    no 

functional  difficulty.  Of  89  cases  reviewed  by  D'Arcy  Power  79  had 
no  recurrence;  in  12  the  range  of  motion  was  somewhat  lessened;  in 
36  there  was  constant  pain,  and  in  11  pain  in  bad  weather.  A  longi- 
tudinal incision  on  the  antero-lateral  aspect,  or  a  transverse  one  at  the 
articular  line  has  been  employed.  Barker^  in  4  of  6  cases  found 
the  meniscus  hidden  in  the  intercondyloid  notch,  drew  it  out  with  a 
hook,  sutured  it  in  place,  and  got  a  good  result,  as  he  did  also  in  the 
other  two  by  fixation.  I  have  always  found  the  anterior  portion  of  the 
internal  meniscus  displaced  inward,  sometimes  detached  at  its  tip, 
sometimes  broken  away  from  the  rest,  and  have  removed  it. 

^  Agnew ;  Surgery,  vol.  ii.  p.  114. 

2  Barker :  Lancet,  September  18,  1897. 


c  '      ^  J      j-i  1       i?    i.1  Clamp  to  prevent  displacement  of  a  semi- 

lormly  good,   the   removal    ot    the  ^       f 


884 


DISLOCATIONS. 


CONGENITAL    DISLOCATIONS. 

Excluding  a  few  cases  in  which  various  malformations  of  the  knee 
have  been  found  in  foetal  monstrosities  showing  many  other  abnormali- 
ties, and  one  or  two  doubtful  cases,  I  found  (1900)  nearly  40^  reported 
cases  of  congenital  dislocation ;  in  22  the  dislocation  was  unilateral, 
backward  in  2,  forward  in  20  with  hyperextension  of  the  leg  upon  the 
thigh,  frequently  so  extreme  that  the  foot  lay  at  the  groin.  Of  the  1 5 
bilateral  dislocations  11  were  forward,  2  backward,  2  inward  ;  6  of  the 
cases  were  stillborn,  and  many  showed  other  defects  of  development.2 

In  a  few  cases  there  is  mention  of  a  blow  or  fall  received  by  the 
mother  while  carrying  the  child,  but  it  cannot  be  maiutained  that  such 
a  cause  is  in  any  case  clear.     The  facility  with  which  the  displacement 

Fig.  469. 


Congenital  dislocation  of  the  knee. 


in  the  unilateral  cases  could  always  be  reduced,  the  normal  shape  of 
the  bones,  and  the  prompt  establishment  of  the  functions  of  the  limb 
point  toward  an  accidental  mechanical  cause;  probably,  in  the  move- 
ments of  the  foetus  the  leg  is  extended  and  becomes  engaged  in  such  a 
position  that  it  cannot  be  flexed,  and  then  by  the  pressure  of  the  wall 
of  the  uterus  hyperextension  is  effected.  Hyperextension  in  conse- 
quence of  unopposed  contraction  of  the  quadriceps  can  hardly  be 
supposed,  for  the  flexors  have  not  been  found  paralyzed.  In  Ham- 
ilton's case  of  double  backward  dislocation  the  flexors  were  con- 
tracted, and  their  tendons  had  to  be  divided  before  the  legs  could  be 
straightened. 

^  In  addition  to  the  hibliography  given  in  the  1st  edition,  see  Joachimstahl,  in  Berlin, 
klin.  Woch.,  October  21,  1889,  p.  923,  4  cases  ;  and  New  York  Medical  Journal,  March  2, 
1889,  6  cases. 

''■  See  also  Musket,  Arch,  fiir  klin.  Chir.,  vol.  liv.  p.  8.")2,  who  collected  82  cases,  of 
which  7  were  real  dislocations,  3  contractures  in  flexion,  72  hyperextensions. 


DISLOCATIONS  OF  THE  KNEE.  885 

In  Friedlebeu's  (bilateral)  the  articular  surface  of  the  tibia  rested 
against  the  front  of  the  lower  end  of  the  femur ;  the  condyles  of  the 
femur  and  the  head  of  the  tibia  were  normally  developed,  the  patella 
normally  attached,  the  capsule  loose  and  large. 

In  Albert's,  a  new-born  child,  both  legs  were  in  dorsal  flexion  at  a 
riffht  angle.  The  articular  surface  of  the  femur  varied  from  the  nor- 
mal.  The  upper  part  of  the  synovial  sac  and  the  ligamentum  alare 
were  lacking.  The  inner  semilunar  cartilage  was  only  a  narrow  strip, 
the  outer  one  was  well  developed;  the  crucial  ligaments  were  very 
broad  and  long,  the  inner  one  being  inserted  further  inward  on  the 
tibia  than  normal ;  on  slight  outward  rotation  of  the  leg  the  two  crucial 
ligaments  became  parallel  to  each  other.  The  popliteal  vessels  and 
nerves  lay  behind  the  external  condyle. 

The  attitude  of  the  limb  at  birth,  in  the  forward  dislocations,  Avas 
hyperextension  to  or  beyond  a  right  angle,  sometimes  so  extreme  that 
the  front  of  the  leg  was  actually  in  contact  with  the  front  of  the  thigh  ; 
usually  there  was  no  deviation  of  the  leg  to  either  side.  It  was  always 
freely  movable,  could  be  brought  down  to  the  position  of  straight  exten- 
sion by  moderate  force,  and  in  most  cases  could  even  be  flexed  nearly 
or  quite  as  far  as  usual  ;  on  removal  of  the  pressure  the  limb  resumed 
the  position  of  hyperextension.  While  the  joint  was  dislocated  the 
condyles  of  the  femur  projected  at  the  back  of  the  popliteal  space,  the 
head  of  the  tibia  lying  against  their  anterior  surface,  and  the  patella 
situated  well  up  on  the  thigh.  In  several  cases  the  skin  on  the  front 
of  the  knee  was  thrown  into  transverse  folds,  in  the  grooves  between 
which  sebaceous  matter  had  sometimes  collected.  Nothing  in  any  case 
indicated  that  the  dislocation  was  recent  and  traumatic,  and  the  experi- 
ments made  by  Hibon  upon  the  bodies  of  newborn  and  stillborn  chil- 
dren show  that  in  a  similar  forcible  dislocation,  even  by  a  force  acting 
continuously  for  several  hours,  detachment  of  one  or  both  epiphyses 
always  occurred,  with,  however,  but  slight  separation  and  not  always 
with  rupture  of  the  periosteum.  In  the  forcible  straightening  of  the 
leg  the  quadriceps  became  tense,  and  in  a  few  cases  this  tension  pre- 
vented further  flexion  of  the  straightened  limb. 

The  results  of  treatment  were  almost  always  very  good,  the  limb 
showing  a  complete  restoration  of  form  and  function  after  a  few  weeks; 
but  in  two  cases  the  result  was  not  entirely  satisfactory.  Six  weeks 
after  birth  the  leg  in  Perier's  case  showed  exaggerated  extension  and 
outward  rotation  ;  the  quadriceps  was  manifestly  retracted,  and  showed 
as  a  tense  cord  whenever  the  attempt  was  made  even  slightly  to  flex 
the  leg.  In  the  hope  of  an  ultimate  return  to  the  normal  condition, 
Gueniot,  wlio  tlien  had  charge  of  the  case,  limited  treatment  to  tlie 
maintenance  of  the  extended  position  and  to  slight  ]>assive  flexion  and 
traction  repeated  two  or  three  times  daily.  In  the  other  case,  Maas, 
the  limb  when  first  seen  was  in  anterior  flexion  at  a  riglit  angle; 
reduction  was  easily  made,  and  the  limb  could  then  be  normally  flexed. 
It  was  placed  in  a  plaster-of- Paris  dressing  for  six  weeks,  and  as  the 
tendency  to  recurrence  had  not  then  entirely  disajipeared  the  dressing 
was  renewed  for  a  time,  and  afterward  a  leather  knee-ea])  was  worn. 
In  its  second  year  the  child  walked  l()r  a  time  without  sii]>|)ort,  but  at 
61 


ggg  DISLOCATIONS. 

the  time  of  the  report,  when  it  was  two  and  a  half  years  old,  there 
was  still  a  tendency  to' anterior  flexion  and  abduction,  and  a  brace  was 
constantly  worn. 

SPONTANEOUS  OR  PATHOLOGICAL  DISLOCATIONS. 

These  are  very  frequent  at  the  knee,  mainly  as  the  result  of  chronic 
disease  involving  the  ligaments  and  the  bones  of  the  joint,  and  of  pro- 
longed maintenance  of  the  partly  flexed  position.  There  are  also 
instauces  on  record  of  sudden  dislocation  due  to  muscular  contraction 
during  an  acute  arthritis,  and  quite  a  number  of  the  class  to  which 
Volkmanu  gave  the  name  defonnations-luxationen,  or  dislocations  by 
deformity,  those  in  which  the  shape  of  the  articular  ends  of  the  bones 
has  been  greatly  changed  without  suppuration,  as  in  arthritis  defor- 
mans and  Charcot's  disease. 

The  principal  displacements  are  backward  and  backward  and  out- 
ward, usually  combined  with  outward  rotation  of  the  leg.  As  a  great 
exception  dislocation  forward  has  occasionally  been  observed, 

Ullman  ^  reports  two  cases  of  bilateral  subluxation  inward  gradually 
produced  by  swinging  the  body  from  side  to  side  while  at  work. 

Examples  of  dislocation  due  to  the  prolonged  action  of  the  flexor 
muscles,  the  knee  being  long  held  partly  flexed  because  of  disease  at 
some  point  in  the  thigh,  are  not  very  uncommon,  and  in  young  people 
its  effect  is  intensified  by  the  exaggerated  growth  of  the  femoral  con- 
dyles downward  by  which  the  lateral  ligaments  become  too  short  to 
permit  the  tibia  to  return  to  its  place.  This  last-mentioned  change 
was  first  pointed  out  by  Volkmann,  in  1874,  and  deserves  to  be  con- 
stantly borne  in  mind,  for  if  the  attempt  is  made  forcibly  to  straighten 
such  a  limb  the  tibia  may  turn  upon  its  anterior  edge  as  a  centre,  so 
that  when  straightened  it  is  found  to  lie  well  behind  its  proper  posi- 
tion, "dislocation  by  leverage,"  as  it  has  been  termed. 

The  dislocations  that  occur  in  the  course  of  chronic  tubercular  or 
other  destructive  disease  must  here  be  passed  with  simple  mention. 

1  Ullmau  :  Ceutralbl.  fiir  Cliir.,  August  11,  1894. 


CHAPTEE  LV. 

DISLOCATIONS  OF  THE  PATELLA. 

General   Considerations — Cause — Outward:     Complete,   incomplete,    vertical- 
Inward— Complete  Reversal — Congenital — Habitual  or  Pathological. 

Dislocations  of  the  patella  are  rare,  less  than  1  per  cent,  of  all 
dislocations,  according  to  the  tables  in  Chapter  XXVII.,  and  the  infre- 
qiiency  with  which  they  have  come  under  the  observation  of  individual 
surgeons  and  the  incompleteness  or  the  obscurity  of  the  reports  of 
many  cases  have  combined  to  make  the  systematic  descriptions  rather 
artificial  and  unsatisfactory.     The  physical  conditions  and  relations  of 
the  patella,  which  is  a  sesamoid  bone  developed  in  the  tendon  of  the 
quadriceps  extensor  and  not  an  integral  part  of  the  joint,  are  entirely 
diiferent  from  those  of  other  bones,  and  the  changes  in  position  and 
relations  which  it  undergoes  in   displacement  are  very  varied.     The 
anterior  articular  surface,  or  trochlea,  of   the    femur  extends  higher 
upon  the    outer    than  the   inner  side  and  presents  a  central  groove 
bounded  laterally  by  a  sharp  margin  from  which   the  internal   and 
external  surfaces  of  the  inner   and   outer  condyles,  respectively,  run 
abruptly  backward,  and  the  outer  condyle  projects  more  sharply  for- 
ward than  the  inner  one  does.     The  articular  or  posterior  surface  of 
the  patella  presents  a  longitudinal  ridge  nearer  its  inner  than  its  outer 
margin  from  which  the  surface  slopes  forward  to  the  e(]ge.     From  each 
lateral  border  of  the  bone  passes  a  strong  aponeurotic  expansion,  the 
so-called  lateral  ligaments  of  the  patella,  portions  of  the  fascia  lata 
which  receive  expansions  from  the  vasti  muscles  and  are  attached  to 
the  tibia;  of  the  outer  one,  the  "ilio-tibial  ligament"  is  the  strongest 
part  and  tends  to  displace  the  patella  outward  when  the  knee  is  flexed. 
A  superficial  layer,  given  off  from  the  fascia  lata  on  the  sides,  crosses 
the  front  of  the  patella  and  is  separated  from  it  by  a  bursa.     In  full 
extension  of  the  knee  the  patella  lies  upon   the  upper  part  of  the 
trochlea  of  the  femur,  but  it  can  be  drawn  almost  completely  above  it 
by  the  forcible  contraction  of  the  quadriceps.     This  muscle  is  inserted 
upon  the  upper  border  and  somewhat  on  each  side  of  the  })atella,  and 
the  long  axis  of  the  muscle  is  inclined  to  that  of  the  patella  and  its 
ligament  as  the  shaft  of  the  femur  is  to  that  of  the  tibia — that  is,  they 
meet  at  an  obtuse  angle  whose  apex  is  directed  inward.     As  a  conse- 
quence of  this  inclination  the  traction  of  the  muscle  tends  to  displace 
the  bone  toward  the  outer  side,  and  this  tendency  is  resisted  by  the 
projection  of  the  anterior  surface  of  the  outer  condyle  and  by  the  inter- 
nal lateral  ligament  of  the  patella. 

The  first  collation  of  recorded  cases  was  made  by  JMalgaignc '  in 

1  Malgaigne  :  Gazette  Medicale,  1836,  p.  4.33. 

(  SST  ) 


888  DISLOCA  TIONS. 

1836;  the  25  cases  which  he  then  collected  were  increased  to  46  in 
1855,  when  he  published  his  work  on  dislocations.  Streubel^  in  1866 
collected  120  cases  and  made  a  number  of  experiments  upon  the 
cadaver.  Elaborate  articles  were  furnished  by  Panas^  in  1872  and 
Berger^  in  1877,  but  the  most  original  and  at  the  same  time  the  most 
recent  one  is  the  paper  by  von  Meyer/  Professor  of  Anatomy  at 
Zurich. 

The  patella  may  be  displaced  to  different  distances  on  the  outer  or 
the  inner  side  while  the  knee  is  extended  or  partly  flexed,  and  with 
such  displacement  may  be  combined  varying  degrees  of  rotation  about 
its  own  longitudinal  axis.  These  combinations  are  so  numerous  and 
varied  that  if  a  classification  should  be  made  according  to  them  it 
would  confuse  rather  than  simplify  their  study  and  description.  As 
some  of  the  most  striking  differences  depend  upon  the  rotation  of  the 
patella  upon  its  vertical  axis,  it  will  perhaps  simplify  the  subject  first 
to  consider  the  conditions  which  determine  the  fixation  of  the  displaced 
bone,  and  in  doing  this  I  shall  speak  only  of  displacements  to  the  outer 
side. 

The  bone  may  be  displaced  to  the  outer  side  by  muscular  action  or 
by  a  force  acting  upon  its  inner  lateral  border ;  as  it  passes  sideways 
along  the  projecting  surface  of  the  condyle  its  outer  border  is  raised 
and  its  inner  border  depressed  into  the  bottom  of  the  trochlear  groove  ; 
if  the  force  continues  to  act  the  patella  is  carried  past  the  edge  of  the 
trochlea  to  the  outer  side  of  the  external  condyle,  and  when  its  longi- 
tudinal ridge  passes  this  edge  the  outer  border  of  the  patella  may  be 
turned  backward  by  the  traction  of  its  outer  lateral  attachments  and 
the  bone  comes  to  rest  w^ith  its  articular  surface  against  the  outer  side 
of  the  condyle,  and  its  anterior  surface  looking  outward ;  or  it  may 
undergo  no  rotation,  and  may  come  to  rest  with  its  inner  border  against 
the  outer  surface  of  the  condyle,  its  anterior  surface  looking  more  or 
less  directly  forward,  and  its  outer  border  projecting  markedly  out- 
ward ;  or,  again,  it  may  undergo  rotation  in  the  opposite  direction  and 
come  to  rest  with  its  inner  border  directed  backward,  its  anterior  sur- 
face looking  inward  against  the  outer  surface  of  the  condyle,  and  its 
outer  border  directed  forward.  These  three  forms  constitute  the 
"complete  outward  dislocations." 

If  the  force  is  not  sufficient  to  carry  the  patella  entirely  past  the 
outer  edge  of  the  trochlea,  the  bone  may  come  to  rest  with  its  inner 
border  in  the  bottom  of  the  trochlear  groove,  its  posterior  surface  rest- 
ing partly  against  the  outer  surface  of  the  trochlea  and  partly  project- 
ing beyond  it,  its  outer  border  directed  forward  and  outward,  and  its 
anterior  surface  looking  forward  and  inward — the  "incomplete  out- 
ward ; "  or  the  rotation  may  be  somewhat  greater,  and  while  the  inner 
border  still  rests  in  the  groove  of  the  trochlea  the  outer  border  looks 
directly  forward,  and  the  anterior  surface  directly  inward — "vertical" 
or  "  edgewise "  dislocation ;  or  the  rotation  may  be  still  greater,  the 
anterior  surface  being  turned  so  as  to  look  directly  backward  and  lie 

^  Streubel :  Schmidt's  Jahrbiicher,  1866,  vol.  cxxix.  p.  311,  and  vol.  cxxx.  p.  54. 

*  Panas:  Diet,  de  Med.  et  Chir.  pratiques,  vol.  xvi.  p.  40,  art.  Genou. 

'  Berger:  Diet.  Eiieyelop.  des  Sc.  Med.,  3d  series,  vol.  v.  p.  334,  art.  Eotule. 

*  Von  Meyer:  Arch,  fiir  klin.  Chirurgie,  1882-3,  vol.  xxviii.  p.  256. 


DISLOCATIONS  OF  THE  PATELLA.  880 

Uf)on  the  front  of  the  trochlea,  and  the  posterior  surface  looking  directly 
forward  under  the  skin — "  complete  reversal." 

It  appears,  then,  that  the  bone  frequently  becomes  fixed,  and  firmly 
fixed,  in  positions  of  apparently  great  instability — that  is,  resting  upon 
the  front  or  side  of  the  femur  only  by  its  narrow  lateral  edge,  and  the 
fixation  which  is  given  to  it  in  these  positions  is  given  by  the  tension 
of  the  soft  parts  attached  to  it  and  by  the 
overlying  fascia.     It  may  be  compared  to  Fig.  470. 

a  stick  on  end  under  a  tightly  stretched  _     g 

sheet,  which  will  stand  not  only  upright,  C->...  r-..   I 

but  also   when    inclined,   so  long  as    its  .-,    -V  -.H.   y  / 

•lower  end  does  not  slip  along  the  ground, 
or  its  upper  along  the  sheet. 

It  also  appears,  in  consequence,  that  the 
bone  may  take  many  intermediate  posi- 
tions between  the  extremes,  and  that  con- 
sequently the  grouping  of  the  different 
positions  must  be  somewhat  arbitrary. 
The  terms  in  general  use  are  complete  and 
incomplete  outward   and    inward   disloca-     ^.  ^     .      .      ^    ^      . 

,•  T         .  ,•      1    /  I  1       Diagram  of  outward  and  edgewise 

tions,   edgewise  ov  vertical  (outward  and  dislocations  of  the  patella. 

inward)  dislocations,  and  complete  reversal 

in  either  of  the  two  directions.  Another  form,  dislocation  downward 
into  the  intercondyloid  notch  or  between  the  external  condyle  and  the 
head  of  the  tibia,  with  some  rotation  about  the  transverse  axis  in  either 
direction,  has  been  observed  several  times  in  the  last  few  years.  I 
have  termed  it  downward  with  rotation  about  the  ti-ansverse  axis.  The 
terms  cimeen,  cuneata,  and  einklemmung  have  been  used  to  indicate  the 
fixation  of  the  patella  like  a  wedge.  Simple  displacements  upward  or 
downward,  the  result  of  rupture  of  the  ligamentum  patellae  or  of  the 
quadriceps,  do  not,  I  think,  deserve  to  be  deemed  dislocations ;  the 
bone  is  not  fixed  in  its  new  position,  and  the  displacement  is  only  an 
incident  of  another  and  controlling  lesion.  Among  the  incomplete  out- 
ward and  inward  dislocations  those  in  which  one  edge  of  the  patella  is 
turned  sharply  forward  differ  from  the  corresponding  edgewise  ones  only 
in  the  degree  of  rotation,  and  the  distinction  between  them  is  not  only 
difficult  to  make  in  practice,  but  also  does  not  seem  worth  preserving. 
I  shall,  therefore,  group  them  all  as  edgewise  dislocations,  and  limit 
the  term  incomplete  to  others  in  which  the  rotation  is  absent  or  slight. 

The  outward  dislocations  are  much  the  more  common  ;  it  is  doubtful 
if  any  really  complete  inward  dislocation  has  been  recorded,  and  of 
Malgaigne's  46  cases  only  6  were  incomplete  inward.  Of  the  vertical 
or  edgewise  dislocations  the  outward  appear  to  be  somewhat  more 
frequent  than  the  inward. 

Cause.  The  cause  and  mode  of  production  of  the  different  forms 
are,  in  many  respects,  the  same.  The  dislocation  may  be  produced 
either  by  muscular  action,  contraction  of  the  quadriceps,  or  by  external 
violence"  acting  directly  upon  the  patella.  Of  the  former  there  are 
many  unquestional)lc  examples  ;  a  nuni  dislocates  the  patella  while 
fencing,  a  woman   by  jumping  backward  and  to  one  side,  a  boy   by 


890 


DISLOCATIONS. 


jumping  upward  and  turning  partly  around  to  strike  a  ball.  Of  the 
latter,  external  violence  acting  directly  upon  the  patella,  the  com- 
mon examples  are  falls  and  blows  upon  the  knee  ;  in  several  instances 
a  man  riding  a  horse  has  struck  his  knee  violently  against  another 
moving  in  the  opposite  direction.  In  a  number  of  cases  it  has  been 
noted  that  the  knee  was  previously  aifected  with  hydrarthrosis,  and  in 
a  few  genu  valgum  existed.  In  the  cases  of  frequent,  or  habitual,  dis- 
location some  such  predisposing  cause  is  supposed  always  to  exist. 

OUTWARD  DISLOCATIONS. 


Fig. 471. 


1.  Complete. 

In  complete  outward  dislocations  the  patella  is  displaced  entirely  to 
the  outer  side  of  the  external  condyle,  against  which  it  rests  either  by 
its  posterior,  cartilaginous  surface,  or,  more  rarely,  by  its  inner  border, 
its  anterior  surface  being  still  directed  forward,  or  by  the  inner  part 
of  its  anterior  surface,  the  outer  border  projecting  forward  and  the 
anterior  surface  looking  inward. 

According  to  von  Meyer,  and  his  opinion  is  based  upon  clinical 
observations,  as  well  as  upon  anatomical  and  experimental  data,  the 
patella  can  reach  this  position  either  by  passing  outward  at  or  above 
the  upper  part  of  the  trochlea  in  complete  extension  or  hyperextension 
of  the  knee,  or  by  passing  outward  and  upward  over  the  lower  border 

of  the  condyle  while  the  knee  is  flexed 
nearly  to  a  right  angle.  In  the  former  case 
the  dislocation  may  be  produced  by  muscular 
action,  the  contraction  of  the  quadriceps  ex- 
tensor, by  which  the  patella  is  raised  so  high 
that  its  passage  is  no  longer  resisted  by  the 
outer  border  of  the  trochlea.  Hyperextension 
of  the  knee  favors  the  displacement  by  carry- 
ing the  patella  still  higher  above  the  trochlea. 
Other  conditions  that  favor  the  displace- 
ment are  exaggerated  outward  rotation  of 
the  leg  and  bending  inward  of  the  knee. 
As  illustrative  examples  Meyer  quotes  cases 
reported  by  Foucart  and  Robert.  A  mus- 
cular young  man  jumping  down  from  a 
stool  (apparently  backward)  felt  a  sharp 
pain,  and  found  he  could  no  longer  stand 
on  the  right  foot ;  examination  showed  an 
outward  dislocation  of  the  patella.  A 
woman,  carrying  a  heavy  burden  upstairs, 
felt  a  sharp  pain  and  a  cracking  in  the  right 
knee,  and  was  unable  to  walk ;  the  patella  was  dislocated  outward. 
External  violence  can  produce  the  dislocation  at  the  same,  upper,  point. 
In  either  case  the  further  displacement  of  the  patella  downward 
upon  the  outer  surface  of  the  condyle  and  its  fixation  there  are  aided 
by  the  subsequent  flexion  of  the  knee  which  involuntarily  follows 
upon  the  sensation  of  an  injury  received  there. 


Complete  dislocation  of  the 
patella  outward.  (Anger.) 


DISLOCATIONS  OF  THE  PATELLA.  891 

In  studying  the  manner  in  which  displacement  took  place,  by  exter- 
nal violence,  while  the  knee  was  partly  flexed,  von  Meyer  found  that 
the  resistance  of  the  ligainentum  patellse  compelled  the  bone  to  move 
in  a  curve  downvv^ard  and  outward,  so  that  it  lodged  over  the  lower 
part  of  the  condyle,  or  even  in  the  groove  between  it  and  the  tibia,  and 
the  tendon  of  the  quadriceps  slipped  sidewise  over  the  edge  of  the 
trochlea,  and  lay  upon  the  outer  surface  of  the  condyle. 

Pathology.  The  pathology  of  the  commoner  form  has  been  studied 
only  in  experiments  upon  the  cadaver  and  in  specimens  of  old  unre- 
duced dislocations,  of  which  seven  cases  have  been  reported.  In  four 
of  these  seven  cases  the  internal  lateral  ligament  of  the  patella  was 
torn,  and  in  one  the  rent  extended  upward  in  the  vastus  internus  more 
than  three  inches  above  the  patella.  Experiments  upon  the  cadaver 
confirm  these  facts.  It  may  be  added  that  in  three  cases  of  long  stand- 
ing the  bones  had  undergone  various  changes ;  in  some  the  patella  was 
hypertrophied,  in  others  atrophied  ;  in  some  it  had  lost  part  or  all  of 
its  articular  cartilage  ;  in  some  the  leg  was  distinctly  rotated  outward, 
presumably  the  result  of  the  traction  exerted  upon  it  through  the 
ligamentum  patellae. 

The  only  examinations  of  uncomplicated  recent  cases  of  which  I 
have  knowledge  are  one  reported  by  Andrews  ^  and  one  in  which  I  did 
an  arthrotoray  to  effect  reduction.  Andrews's  specimen  was  obtained 
by  amputation,  which  was  rendered  necessary  by  a  compound  fracture 
of  the  leg.  The  displacement  was  of  the  rare  form  in  which  the 
patella  has  undergone  no  deviation  about  its  longitudinal  axis  and 
rests  against  the  external  condyle  only  by  its  inner  border  (Fig.  472). 
The  patient  had  been  run  over  by  a  freight  car. 
"The  patella  was  found    shoved  nearly  straight  out-  Fig.  472. 

ward  with  its  inner  edge  resting  firmly  against  the 
outer  condyle,  and  with  its  front  and  back  surfaces 
presenting  in  a  nearly  normal  direction.  ...  At  the 
place  where  the  inner  border  of  the  patella  rested 
against  the  femur  the  shell  and  spongy  tissue  of  the 
condyle  were  crushed  in,  making  an  oval  or  spoon- 
shaped  hollow  about  one  inch  long  and  five-eighths 
inch  wide.  The  sharp  inner  edge  of  the  patella  rested 
firmly  in  this  hollow  and  was  thus  effectually  pre- 
vented from  slipping.  The  rest  of  the  patella  was 
stoutly  held  in  position,  like  a  tent-pole  or  derrick, 
by  tight  bands  drawing  in  three  different  directions, 
as  follows :    1.  By  a  portion   of  the  vastus  externus      !^f\''''\^  '^^'^^^ 

.^r  ,  -,.  11*^'  dislocation  oi 

muscle  dmwmg  the  outer  angle  upward,  mward,  and    ^j^^  ,,ateiia   out- 
backward.     2.  By  a  part  of  the   rectus   femoris,  not    ward. 
represented  in  the  figure,  but  drawing  upward,  inward, 
and  forward.     3.  By  the  ligamentum  patella,  drawing  downward  and 
inward . 

"  The  vastus  internus  was  torn  off.  The  inner  half  of  ihe  rectus 
was  torn  off  with  the  vastus  internus,  and  the  lateral  attachments  of 
the  capsular  ligaments  to  the  sides  of  the  patella  were  effectually  ripped 
away,  but  the  outer  part  of  the  rectus  was  still  attached." 

1  Andrews:  Annals  of  Anatomy  and  Surgery,  1883,  vol.  vii.  p.  199. 


892 


DISLOCATIONS. 


Fig.  473. 


My  patient  was  a  well-grown  lad  sixteen  years  old  who  fell  while  coast- 
ing on  skis,  his  flexed  knee  striking  against  a  rail.  The  patella  stood 
out  from  the  side,  as  in  Andrews's  case,  but  the  physician  who  sought 
to  reduce  it  gave  it  a  half  turn,  so  that  when  I  saw  him  its  outer  border 
projected  forward  well  above  the  level  of  the  condyle,  the  knee  being 
in  straight  extension.  I  opened  the  joint  widely  in  front  and  found 
the  internal  expansion  widely  torn  and  the  vastus  internus  detached 
from  the  patella.  Both  condyles  projected  through  the  rent,  and  the  lig- 
araentum  patellae  was  engaged  beneath  and  behind  the  edge  of  the  outer 
condyle,  eifectually  preventing  reduction  until  after  it  had  been  pried 
out  of  its  position  with  an  elevator.  The  patient  made  a  good  recovery. 
Symptoms.  The  symptoms  are  loss  of  power  to  stand  upon  the  limb 
or  actively  to  move  the  knee,  pain,  and  deformity.  The  knee  is  usually 
partly  flexed,  but  occasionally  has  been  found  fully  extended.  Passive 
motion  is  painful,  complete  extension  usually  possible,  further  flexion 
rarely  possible. 

The  knee  appears  broadened  and  flattened  anteriorly ;  the  normal 
prominence  of  the  patella  is  lost,  and  in  its  place  is  a  depression  through 
which  the  anterior  articular  surface  of  the  condyles  can  be  distinctly 
traced  unless  the  swelling  is  too  great.  The  patella  can  be  readily  felt 
upon  the  outer  side  of  the  condyle,  and  the  tendon  of  the  quadriceps 

and  the  ligaraentum  patellse  show  as  tense 
bands  under  the  skin.  Usually  the  patella 
rests  with  its  articular  surface  against  the 
outer  surface  of  the  condyle  and  its  inner 
border  directed  forward,  but,  as  has  been 
already  said,  it  may  stand  directly  out  from 
the  condyle,  resting  against  it  by  its  inner 
border  only,  or  it  may  be  rotated  in  the  op- 
posite direction  so  that  its  outer  border  is 
directly  in  front. 

Treatment.  The  method  of  treatment  that 
has  proved  the  most  successful  is  one  pro- 
posed more  than  a  hundred  years  ago  by 
Valentin,  which  consists  in  full  extension 
of  the  knee  and  flexion  of  the  hip  to  relax 
the  quadriceps,  followed  by  direct  pressure 
with  the  hands  upon  the  patella ;  it  may  be 
necessary  to  increase  the  laxity  of  the  ten- 
don of  the  quadriceps  by  pressing  the  lower 
part  of  the  muscle  downward  toward  the 
knee.  Possibly  a  device  which  Duplay  em- 
ployed successfully  in  a  vertical  dislocation 
might  be  used,  if  pressure  with  the  hands 
failed ;  he  inserted  the  points  of  a  strong 
double  hook  through  the  skin,  engaged  them  under  the  edge  or  in  the 
anterior  surface  of  the  patella,  and  drew  the  bone  forward.  When  the 
ligamentum  patellse  is  engaged  behind  the  condyle,  as  in  my  case, 
reduction  without  arthrotomy  is  impossible. 

In  cases  that  have  remained  unreduced  the  usefulness  of  the  limb 


Dislocation  of  tlie    patella  out- 
ward.    (Duplay.) 


DISLOCATIONS  OF  THE  PATELLA.  893 

has  sometimes  been  well  restored,  the  patients  being  able  to  walk  freely 
and  tronbled  only  in  making  complete  extension.  In  other  cases,  again, 
the  disability  has  been  great,  the  knee  being  stiff  and  the  patient  able 
to  walk  only  with  crutches.  Occasionally  the  accident  is  followed  by 
a  marked  tendency  to  recurrence  on  flexion  of  the  knee. 

2.  Incomplete. 

The  cases  to  which  I  limit  this  group  are  those  in  which  the  dislo- 
cation takes  place  while  the  knee  is  extended,  and  in  which  the  patella 
rests  above  and  partly  to  the  outside  of  the  outer  part  of  the  femoral 
trochlea,  its  apex  being  probably  still  on  the  median  side  of  the  crest. 
It  is  to  be  remembered  that  in  most  systematic  descriptions  the  group 
is  made  also  to  include  cases  of  moderate  edgewise  or  vertical  displace- 
ment, those  in  which  the  inner  border  of  the  patella  rests  in  the  hollow 
of  the  trochlea  and  the  outer  border  projects  outward  and  forward  ; 
but  still  the  majority  of  the  reported  cases  are  of  the  kind  to  which  I 
have  restricted  the  use  of  the  term.  There  are,  however,  cases  of 
habitual  dislocation  in  which  the  patella  moves  outward  during  flexion 
of  the  knee  and  the  outer  border  turns  backward,  which  might  properly 
be  termed  incomplete.  Malgaigne  ^  reports  one  such  in  which  the  con- 
dition followed  a  primary  traumatic  dislocation,  and  a  number  have 
been  reported  in  which  the  condition  developed  gradually  or  was 
thought  to  have  existed  at  birth. 

The  causes  are  essentially  the  same  as  those  which  produce  the  com- 
plete outward  dislocations  in  which  the  patella  escapes  at  or  above  the 
upper  part  of  the  trochlea,  that  is,  muscular  action  and  external  vio- 
lence received  while  the  knee  is  fully  extended  or  even  hyperextended. 

Von  Meyer  finds  the  explanation  of  the  incompleteness  of  the  dis- 
location in  the  supposition  that  the  lateral  movement  of  the  patella 
takes  place  while  it  is  still  at  a  lower  point  upon  the  femur  than  it  is 
when  it  undergoes  displacement  outward ;  the  outer  margin  of  the 
trochlea  engages  in  the  sulcus  at  the  junction  of  the  patella  and  liga- 
mentum  patellse,  and  thus  the  bone  is  prevented  from  being  drawn 
further  outward  by  the  traction  of  the  ilio-tibial  band. 

Direct  examination  has  been  reported  in  only  one  case,  and  that  an 
old  one,  Diday ;  ^  the  specimen  came  from  a  man  thirty-four  years  old  ; 
the  deformed  patella  rested  on  the  external  condyle  and  was  prevented 
from  moving  inward  by  a  bony  ridge  which  occupied  the  trochlea  ;  the 
articular  surface  extended  an  inch  higher  upon  the  outer  than  upon 
the  inner  condyle.     The  patient  walked  without  difficulty. 

The  limb  is  in  extension,  and  any  attempt  to  flex  is  painful.  The 
inner  half  of  the  trochlea  can  be  distinctly  traced  with  the  finger,  and 
tiie  patella  can  be  recognized  above  and  to  the  outer  side  of  its  normal 
position,  with  its  anterior  surface  looking  almost  directly  forward,  and 
if  inclined  at  all  it  appears  to  be  usually  inclined  outward. 

The  treatment  is  the  same  as  that  of  the  complete  form  :  flexion  of 
the  hip  and  extension  of  the  knee  to  relax  the  quadricejis,  followed  by 
direct  pressure  inward  upon  the  patella.  Reduction  is  easy  and  some- 
times spontaneous. 

1  Malgaigne:  Loc.  cit.,  p.  912.        "^  Diday:  Bull,  de  la  Societe  Anatomiqiio,  18.3(),  p. 297. 


894  DISLOCATIONS. 

3.  Outward  Edgewise  or  Vertical  Dislocations. 

According  to  Malgaigne  this  form  of  dislocation  was  first  reported 
in  1777  by  Nannoni,  an  Italian  surgeon,  who  communicated  two  cases 
to  the  Academic  royale  de  Chirurgie.  The  subject  was  not  again  men- 
tioned until  Malgaigne,  in  1836,  gave  a  description  of  it.  Since  that 
time  a  considerable  number  of  cases  have  been  reported  ;  without  mak' 
ing  a  very  thorough  search  I  found  about  thirty,  five  of  which  were 
reported  in  the  New  York  Medical  Record  between  the  years  1873  and 
1879,  and  in  this  enumeration  I  have  not  included  cases  reported  as 
incomplete  outward  dislocations,  although  I  include  such  in  the  class- 
ification. 

The  dislocation  is  characterized  by  a  displacement  outward  of  the 
patella  and  its  rotation  upon  its  longitudinal  axis,  by  which  its  inner 
border  is  brought  to  rest  at  or  near  the  bottom  of  the  groove  of  the 
trochlea,  while  the  outer  border  projects  more  or  less  directly  forward 
and  its  anterior  surface  looks  inward ;  it  is  said  by  Panas  that  its  apex 
is  also  directed  slightly  backward. 

Muscular  action  is  the  most  frequent  cause,  and  in  some  cases  the 
contraction  of  the  muscle  appears  not  to  have  been  forcible,  as  in 
Martin's  ^  patient,  a  young  girl,  who  caused  the  dislocation  by  moving 
in  bed  ;  in  others  more  force  has  been  exerted,  as  a  boy  in  throwing  a 
snowball,  a  man  in  wrestling,  another  in  stumbling,  another  in  jump- 
ing. External  violence  is  a  less  frequent  cause  ;  a  blow  upon  the  inner 
edge  of  the  patella  by  which  the  bone  is  pushed  outward,  its  inner 
border  depressed  into  the  hollow  of  the  trochlea,  and  its  outer  border 
raised  by  the  passage  of  the  bone  along  the  slope  of  the  external  con- 
dyle. The  mode  of  production  by  muscular  action  has  not  been  made 
clear. 

The  patella  may  rest  partly  against  the  projecting  outer  portion  of 
the  trochlea,  or  it  may  touch  the  femur  only  by  its  inner  edge  even 
when  its  outer  border  still  lies  somewhat  to  the  outer  side  of  a  sagittal 
plane  passing  through  the  inner  one,  and  in  one  case,  Payen,  quoted 
by  Malgaigne,  the  patella  had  turned  more  than  90  degrees,  so  that  its 
outer  border  lay  a  little  to  the  inner  side  of  the  inner  border.  Its 
fixation  in  this  position  without  lateral  support  must  be  attributed  to 
the  tension  of  the  overlying  soft  parts  and  the  untorn  parts  of  the 
capsule,  for  in  one  case  in  which  both  the  tendon  of  the  quadriceps 
and  the  ligamentum  patellse  were  cut  subcutaneously  by  the  surgeon 
in  the  effort  to  reduce,  the  bone  remained  as  firmly  fixed  as  before. 

The  knee  is  generally  extended,  but  in  some  cases  it  was  flexed  half 
way  to  a  right  angle,  and  is  usually  immovable  because  of  pain.  The 
deformity  is  characterized  by  the  sharp  projection  of  the  outer  border 
of  the  patella  in  front,  on  each  side  of  which  the  skin  is  depressed  so 
that  the  anterior  and  articular  surfaces  of  the  patella  can  be  felt,  but 
sometimes  the  skin  is  stretched  tightly  toward  each  side. 

The  most  successful  treatment  has  been  that  recommended  for  the 
preceding  forms  :  flexion  of  the  hip,  extension  of  the  knee,  and  pressure 
upon  the  patella,  the  latter  being  so  directed  as  to  force  the  projecting 

1  Martin  :  Arch.  gen.  de  Med.,  1831,  vol.  xxvi.  p.  259. 


DISLOCATIONS  OF  THE  PATELLA.  895 

outer  border  outward  and  backward,  but  this  has  failed  in  several  cases 
in  which  reduction  was  afterward  obtained  by  forced  flexion  of  the  leg 
or,  in  one  case,  by  getting  the  patient  forcibly  to  contract  the  quadriceps 
and  then  pressing  upon  the  patella  after  it  had  been  thus  drawn  upward. 
Possibly  Duplay's  device,  above  mentioned,  of  drawing  the  patella  for- 
ward with  a  strong  sharp  hook,  would  be  of  use  by  diminishing  the 
friction  between  it  and  the  femur.  Eben  Watson,  and  others  following 
his  example,  succeeded  by  slightly  flexing  the  leg  upon  the  thigh  during 
anaesthesia,  pressing  the  patella  moderately  outward,  and  then  suddenly 
extending  the  leg.  Three  surgeons  have  resorted  to  section  of  the  liga- 
mentum  ])atell8e,  and  one  of  them  also  to  that  of  the  tendon  of  the 
quadriceps,  but  without  success,  and  in  the  last  one  the  joint  suppu- 
rated and  the  patient  died. 

INWARD  DISLOCATIONS. 

These  are  so  similar  to  the  outward  dislocations  in  their  nature, 
causes,  symptoms,  and  treatment  that  a  detailed  description  is  unnec- 
essary. 

Complete  Inward. 

This  dislocation  is  denied  by  several  authors,  the  only  alleged  cases 
being  those  of  Putegnat  and  Walther,  both  quoted  by  Malgaigne.  The 
former  \vas  traumatic  in  origin,  but  when  the  patient  came  under 
observation  the  condition  was  that  of  habitual  dislocation  :  the  patient, 
a  girl  thirteen  and  a  half  years  old,  had  fallen  upon  her  knees  five 
years  before,  and  since  that  time  both  patellae  had  been  so  freely  mov- 
able that  she  sometimes  amused  herself  by  dislocating  and  reducing 
them  more  than  a  hundred  times  in  an  hour.  The  right  patella  could 
be  more  easily  dislocated  outward,  the  left  one  inward ;  but  both  could 
be  dislocated  so  completely  inward  that  their  anterior  surfaces  were 
exactly  in  contact  when  the  knees  were  brought  together.  The  liga- 
ments were  so  relaxed  that  the  legs  could  not  be  completely  extended 
by  the  contraction  of  the  quadriceps. 

Of  Walther's  case,  nothing  is  known  but  a  brief  description  in 
Latin  of  a  specimen  in  a  museum  at  Berlin.  Malgaigne  thought  it 
might  be  a  complete  inward  dislocation,  but  admits  that  its  character 
is  uncertain. 

Incomplete  Inward. 

Of  incomplete  inward  dislocation  only  one  case  has  been  reported,  by 
Key^ ;  it  also  was  quoted  by  Malgaigne.  The  patient,  a  girl  twenty 
years  old,  slipped  and  fell ;  she  felt  great  pain  in  the  left  knee,  and 
was  unable  to  walk.  "The  patella  was  found  resting  on  the  inner 
condyle,  the  outer  part  of  its  articulating  surface  being  supported 
obliquely  by  the  projecting  edge  of  the  trochlea  of  the  femur.  Gentle 
pressure  on  the  inner  edge  of  the  patella,  as  the  limb  lay  on  the  bed, 
reduced  it  to  its  natural  position."  The  joint  suppurated,  and  appar- 
ently the  patient  died  or  the  limb  was  amputated.  The  tendon  of  the 
vastus  externus  was  partly  torn  through. 

1  Key :  Guy's  Hospital  Keports,  1836,  vol.  i.  p.  260. 


896  DISLOCATIONS. 

Inward  Edgewise  or  Vertical  Dislocation. 

This  seems  to  be  nearly  as  frequent  as  the  corresponding  outward 
form.  Possibly  its  relative  frequency  and  the  rarity  or  absence  of  the 
complete  and  incomplete  inward  forms  are  to  be  explained  by  the 
greater  projection  inward  of  the  internal  condyle,  and  the  relative 
shortness  of  the  ligamentum  patellse,  which  prevents  the  patella  from 
reaching  that  side  of  the  condyle. 

COMPLETE  REVERSAL. 

Complete  reversal,  the  outer  border  passing  in  front  to  the  inner  side, 
so  that  the  anterior  surface  rests  against  the  trochlea  and  the  articular 
surface  is  directed  forward,  has  been  reported  in  only  two  cases,  which 
are  briefly  quoted  by  Malgaigne  as  follows:  "In  1752  J.  Sue  saw  a 
dislocation  produced  by  muscular  action  in  which  he  clearly  recog- 
nized a  two-thirds  reversal  of  the  patella  from  without  inward  without 
any  evidence  of  rupture  of  the  ligaments.  Subsequently  Hevin  said 
that  he  had  heard  Bruyeres  read  before  the  Academic  royal  de  Chir- 
urgie  the  details  of  a  total  reversal  of  the  patella  upside  down,  also 
without  rupture  of  the  ligaments;  in  the  latter  case  the  cause  was  a 
blow  received  upon  the  inner  part  of  the  knee." 

Complete  reversal,  the  inner  border  passing  in  front  to  the  outer 
side,  has  been  reported  in  three  cases,  Castara,  quoted  by  Malgaigne, 
Wragg,^  and  Gaulke.'"' 

Castara's  patient,  a  girl  seventeen  years  old,  bent  forward  to  lift  a 
book  from  a  table,  resting  her  weight  upon  the  extended  right  leg,  and 
pressing  the  outer  border  of  the  patella  against  the  edge  (>f  a  chair ; 
she  suddenly  cried  out,  and  Castara,  summoned  immediately,  found 
the  leg  partly  flexed,  and  could  extend  it  but  very  little.  The  patella 
rested  by  its  outer  border  upon  the  outer  and  upper  part  of  the  trochlea 
of  the  femur,  which  it  covered  only  over  a  breadth  of  a  quarter  of  an 
inch  ;  its  inner  border  inclined  outward  and  projected  in  this  direction 
two  and  a  half  centimetres,  its  articular  surface  looking  forward  and 
inward.  The  tendon  of  the  quadriceps  and  the  ligamentum  patellae 
each  formed  a  quite  thick  and  hard  rounded  cord  above  and  below. 
The  surgeon  grasped  the  bone  with  his  thumbs  and  forefingers,  and  by 
a  simple  movement  of  rotation  from  behind  forward,  and  from  without 
inward,  restored  it  easily  to  its  place. 

Wragg's  patient  was  a  negro,  who  had  been  struck  upon  the  outer 
side  of  the  right  patella.  The  limb  was  extended  and  immovable. 
The  inner  border  of  the  patella  had  turned  forward  and  outward,  and 
lay  about  half  an  inch  to  the  outside  of  the  normal  position  of  the 
outer  border;  the  outer  border  could  be  felt  deep  in  the  trochlea  about 
half  an  inch  from  its  inner  edge.  The  tendon  of  the  quadriceps  and 
the  ligamentum  patellae  showed  under  the  skin  as  hard  twisted  cords; 
very  little  passive  motion  at  the  knee.     The  dislocation  was  reduced 

^Wragg:  Charleston  Medical  Journal,  May,  1856,  abstract  in  Schmidt's  Jahrbiicber, 
1856,  vol.  xci.  p.  362. 

2  Gaulke :  Deutsche  Klinik,  1863,  p.  108. 


DISLOCATIONS  OF  THE  PATELLA.  897 

easily  by  pressing  with  the  thumbs  against  the  projecting  border,  and 
with  the  index-  and  middle  fingers  against  the  outer  border  in  the 
opposite  direction.  The  reaction  was  slight,  and  the  patient  made  a 
good  recovery. 

Gaulke's  patient,  a  girl  seventeen  years  old,  injured  her  knee  in  a 
fall  from  a  horse,  and  was  not  seen  by  him  until  ten  days  after  the 
accident.  "  The  patella  lay  entirely  upon  the  outer  condyle  of  the 
femur,  and  had  been  so  turned  about  its  longitudinal  axis  that  its  pos- 
terior surface  looked  forward  and  inward,  and  the  anterior  surface 
backward  and  outward."  After  several  failures  he  reduced  by  making 
pressure  against  the  projecting  inner  border  with  one  jaw  of  a  vise, 
such  as  is  used  by  carpenters  to  hold  pieces  of  wood  that  have  been 
freshly  glued  together,  the  counter-pressure  being  made  with  the  other 
jaw  against  the  internal  condyle.  The  force  of  the  screw  was  so 
applied  as  to  press  the  inner  border  of  the  patella  forward  and  inward, 
while  its  outer  border  was  expected  to  move  along  the  outer  slope  of 
the  trochlea.  After  many  efforts,  the  patella  suddenly  moved  with  a 
snap,  turned  about  its  long  axis,  and  fell  back  into  place.  The  patient 
recovered  in  a  fortnight. 

Downward  with  Rotation  About  Transverse  Axis. 

In  this  the  patella  is  displaced  downward  and  lodged  between  the 
femur  and  tibia  with  some  rotation  about  its  transverse  axis  in  one 
direction  or  the  other.  Eight  cases  ^  have  been  reported.  In  all  the 
cause  was  external  violence  acting  on  the  knee,  probably  while  flexed, 
and  in  two  cases  causing  also  a  subluxation  of  the  knee. 

The  slightest  form  is  represented  by  Newman's  case.  A  fall  upon  the 
knee ;  "  the  lower  border  of  the  patella  was  wedged  in  between  the 
head  of  the  tibia  and  the  condyles  of  the  femur,  .  .  .  and  the  tendon 
of  the  quadriceps  extensor  muscle  was  thrown  forward."  The  dislo- 
cation was  easily  reduced.      It  is  the  only  case  of  the  kind. 

In  5  cases  (Midelfart,  Deaderick,  Schmidt,  Rutherford,  Cheesman) 
the  upper  border  was  turned  backward  into  the  cleft  between  the  femur 
and  tibia  and  the  quadriceps  was  torn  away  from  it.  In  all  but  one 
the  position  was  determined  by  inspection  after  incision ;  in  Deader- 
ick's  it  was  probably  turned  the  same  way.  Deaderick  reduced  by 
manipulation  after  many  efforts  ;  he  thinks  binding  tissues  were  torn 
in  the  course  of  the  unsuccessful  attempts  and  that  this  made  the 
reduction  possible  at  last  by  a  manipulation  which  had  previously 
failed  many  times.  In  most  of  the  others  considerable  force  was 
needed  to  dislodge  the  bone  after  it  had  been  exposed.  This  was 
attributed  by  some  to  the  tension  of  the  ligamentum  patellae,  but  I 
should  think  that  engagement  of  the  torn  edge  of  the  lateral  expan- 
sions on  the  side  of  the  condyles  was  at  least  a  contributing  cause.  All 
these  patients  made  good  recovery. 

In  2  cases  (Szumann,  Kiittner)  the  patella  lay  between  the  outer 

'  Midelfart,  Ctlblatt  fiir  Cliir.,  1888,  p.  Hfi  ;  Szuman,  Beilage  znm  Ctlblatt  fiir  Cliir., 
1889.  No.  29,  p.  101;  Deaderick,  Annals  of  Surg.,  vol.  xi.  p.  102;  Schmidt,  Ctlblatt  fiir 
Chir.,  1900,  p.  1023  .  Newman  and  Riitbcrford,  Lancet,  June  22,  1901,  p.  1701  ;  Kiittner. 
Beitriige  zurklin.  Cliir.,  vol.  xlii.    p.  553  ;  (.heesman,  Annals  of  Surg.,  vol.  xli.    p.  108. 


898  DISLOCATIONS. 

coDclyle  of  the  femur  and  the  tibia,  its  articular  surface  against  the 
femur  in  Szumaun's,  against  the  tibia  in  Kiittner's,  and  the  quadriceps 
was  tightly  stretched  across  the  outer  side  of  the  condyle,  the  end  of 
the  femur  projecting  through  a  large  rent  in  the  internal  lateral  expan- 
sion. The  external  lateral  ligament  was  torn  in  Kiittner's,  both  lateral 
ligaments  in  Szumann's,  and  the  crucial  ligaments  in  both.  In  Kiitt- 
ner's the  skin  was  torn  and  he  amputated.  Szumann  reduced  with 
difficulty  after  having  opened  the  joint  and  divided  the  ligamentum 
patellge.  It  seems  probable  that  in  both  cases  the  dislocation  was  first 
to  the  outer  side,  while  the  knee  was  flexed,  and  that  then  forced 
adduction  of  the  leg  tore  the  lateral  and  crucial  ligaments  and  opened 
a  gap  into  which  the  patella  was  drawn.  In  both  cases  the  violence 
was  great  and  repeated  ;  in  Szumann's  the  leg  was  caught  in  machinery, 
iu  Kiittner's  in  a  wagon  wheel.  Szumann's  made  a  good  recovery. 
For  Lannelongue's  and  Potel's  cases  see  the  next  two  sections. 

CONGENITAL    DISLOCATIONS. 

In  a  number  of  reported  cases  the  term  congenital  has  been  used 
although  the  writers  knew  that  the  dislocation  had  first  appeared  long 
after  birtli ;  in  most  of  the  others  it  has  not  been  possible  to  ascertain 
with  certainty  the  date  of  the  appearance  of  the  condition,  and  in  many 
the  probability  is  very  great  that  it  had  been  gradually  developed  long 
after  birth.  The  reported  cases  in  which  it  is  reasonably  certain  that 
the  condition  existed  at  birth  are  not  numerous,  perhaps  fifteen  or 
twenty,  but  if  to  these  are  added  the  other  cases  which  several  of  the 
patients  have  said  existed  in  other  members  of  their  families,  the  num- 
ber becomes  considerably  increased.  The  principal  paper  upon  the 
subject  is  one  by  Zielewicz  ^ ;  Bessel-Hagen  ^  read  one  before  the  Ber- 
lin Medical  Society,  and  presented  2  cases,  but  the  published  abstract 
is  very  short.  Zielewicz's  paper  gives  the  details  of  13  cases,  in  3  of 
which  the  patella  M-as  dislocated  up^vard  with  elongation  of  its  liga- 
ment ;  in  the  remaining  10  the  dislocation  was  outward.  The  con- 
genital character  of  the  first  3  is  uncertain.  Of  the  outward  ones  in 
which  the  sex  is  noted,  6  were  males,  3  females  ;  in  5  both  patellae  were 
dislocated,  and  in  all  the  patients  were  able  to  make  good  use  of  the 
limb. 

Lannelongue  ^  reported  the  case  of  a  boy  twelve  years  of  age  in  whom 
since  birth  the  very  small  patella  disappeared,  on  semi-flexion  of  the 
joint,  into  the  space  between  the  femur  and  the  tibia  so  that  only  its 
apex  could  be  felt.  The  ligamentum  patella?  was  only  one  centimetre 
long.  It  has  been  grouped  with  those  of  the  preceding  section,  but  I 
do  not  think  it  should  be  termed  a  dislocation. 

Bessel-Hagen  points  out  that  the  cases  may  be  grouped  in  three 
classes  :  1.  The  incomplete,  in  which  the  patella  lies  upon  the  outer 
condyle  when  the  knee  is  extended,  and  returns  to  its  normal  place 
when  the  knee  is  flexed  ;  2,  complete  intermittent,  in  which  the  displace- 

1  Zielewicz:  Berlin,  klin.  Wochenschrift,  1869,  vol.  vi.  p.  25. 
-  Bessel-Hagen  :  Deutsche  med.  Wochenschrift,  1881,  p.  45. 
3  Lannelongue  :  Bulletin  Medical,  1895,  p.  894. 


DISLOCATIONS  OF  THE  PATELLA.  899 

ment  occurs  during  flexion  ;  3,  complete  'permanent,  in  which  the  dis- 
placement is  increased  during  flexion,  and  is  not  overcome  during 
extension. 

Caswell^  reported  a  case  of  congenital  dislocation  of  both  patellae  in 
a  man,  forty-three  years  old,  who  said  that  five  members  of  his  family, 
in  three  generations,  had  the  same  deformity — his  father,  sister,  son, 
and  nephew.  Dr.  Caswell  examined  the  son  and  confirmed  the  state- 
ment to  that  extent, 

Shapleigh  ^  saw  a  man,  thirty-nine  years  old,  both  of  whose  patellae 
"  were  dislocated  outward,  resting  on  the  upper  and  outer  surface  of 
the  external  condyle  of  the  femur."  They  were  of  normal  size.  The 
patient  said  the  condition  had  existed  from  birth,  and  that  his  grand- 
father, father,  and  one  of  his  own  children,  four  generations,  had  the 
same  deformity.  The  man  walked  without  difficulty  and  had  served 
as  a  soldier  during  the  war. 

An  anonymous  writer^  reported  a  case  of  congenital  dislocation  of 
both  patellae  in  a  girl  whose  father^  aunt,  and  aunt's  daughter  were  in 
the  same  condition. 

HABITUAL    OR    PATHOLOGICAL    DISLOCATIONS.* 

A  number  of  varying  conditions  in  the  bones  or  ligaments  of  the 
knee  may  have  for  consequence  the  frequent,  even  habitual,  dislocation 
of  the  patella  in  certain  positions  or  movements.  Almost  without 
exception,  these  dislocations  are  to  the  outer  side  and  complete.  Many 
cases  reported  as  congenital  are  probably  of  this  character ;  Isemeyer/ 
indeed,  published  an  elaborate  paper  on  the  subject  in  which  he  claimed 
that  all  reported  cases  of  congenital  dislocation  were  really  pathological 
ones. 

Among  the  alleged  causes  are  relaxation  of  the  ligaments,  chronic 
arthritis  of  different  kinds,  malformations  of  the  knee,  especially  genu 
valgum,  and  injury  of  the  lower  part  of  the  vastus  internus. 

In  genu  valgum  the  increased  abduction  of  the  leg  upon  the  thigh 
produces  a  corresponding  exaggeration  of  the  angle  between  the  quad- 
riceps and  the  ligamentum  patellae  in  consequence  of  which  the  con- 
traction of  the  muscle  constantly  tends  to  draw  the  patella  outward, 
and  if  the  patella  passes  to  the  outer  side  of  the  outer  condyle  the 
muscle  then  aids  still  further  to  abduct  the  leg  and  increase  its  devia- 
tion. Indeed,  in  some  of  the  reported  cases  it  has  remained  in  doubt 
whether  the  abduction  of  the  leg  preceded  or  was  itself  the  conse- 
quence of  the  dislocation  of  the  patella. 

Condamin®  reported  a  case  in  which  persistent  outward  displacement 
took  place  gradually  in  consequence  of  operative  division  of  the  lower 
portion  of  the  vastus  internus  in  the  treatment  of  an  osteomyelitio 
abscess. 

1  Caswell:  American  Journal  oC  the  Medical  Sciences,  Jul.v,  1865. 

2  Shapleigli:  Boston  Medical  and  Surgical  Journal,  1881,  vol.  cv.  p.  252. 
•'  New  York  Medical  Journal,  188.^,  vol.  xlii.  p.  27. 

*  For  a  full  discussion,  9.1  cases,  see  Delia  Vedova,  Arch,  de  Ortopedia,  1902. 

*  Isemeyer :   Arch,  fiir  klin.  Chirurgie,  1H()6,  vol.  viii.  p.  1. 

*  Coudamiu  :  Lyou  Med.,  Septemher  :{!),  1888. 


900  -D ISL  0  CA  TIONS. 

The  patella  is  habitually  very  movable,  and  the  dislocation  takes 
place  or  is  increased  during  flexion  of  the  knee  and  is  reduced  or 
diminished  during  extension.  The  functions  of  the  limb  are  more  or 
less  interfered  with,  complete  voluntary  extension  being  difficult  or 
impossible.  The  femur  tends  to  rotate  inward,  and  the  leg  outward 
and  to  become  abducted. 

Potel  ^  saw  a  boy  fifteen  years  old  with  hip  disease  and  an  acquired 
genu  recurvatum  whose  patella  disappeared  on  semi-flexion  as  in  Lau- 
nelongue's  case  quoted  in  the  preceding  section.  The  ligaraentum 
patellse  was  very  short.  Its  right  to  be  deemed  a  dislocation  is  open 
to  the  same  objection. 

A  case  which  resembles  Putegnat's  of  complete  inward  dislocation 
in  the  facility  with  which  the  patient  could  rapidly  produce  and  reduce 
the  dislocation  by  muscular  action  is  reported  by  Albert  ;^  the  patient 
was  a  boy,  sixteen  years  old,  with  genu  valgum  on  the  aflected  side. 
When  the  knee  was  held  at  an  angle  of  160  degrees  he  could  repeat 
the  production  and  reduction  with  great  rapidity  and  ease.  Flexion 
at  150  degrees  was  the  limit  at  which  voluntary  reduction  could  be 
made  ;  voluntary  dislocation  was  possible  even  when  flexion  was  carried 
to  90  degrees. 

The  treatment  consists  in  the  wearing  of  a  knee-cap  designed  to 
oppose  the  displacement  during  flexion  or  to  restrict  the  flexion  to  the 
range  beyond  which  the  displacement  took  place. 

Roux^  relieved  a  case  of  habitual  dislocation  outward  following 
rupture  of  the  aponeurosis  on  the  inner  side  by  dividing  the  vastus 
externus,  suturing  the  rent  on  the  inner  side,  and  displacing  the  inser- 
tion of  the  ligamentum  patellae  upon  the  tibia  half  an  inch  inward. 
Bradford*  did  the  same  with  success. 

Another  French  surgeon  (I  have  mislaid  the  reference)  relieved  the 
condition  by  narrowing  the  internal  lateral  expansion  by  means  of 
three  silk  sutures  so  placed  as  to  make  a  longitudinal  tuck  in  it ;  others 
have  excised  a  piece  and  closed  the  opening  with  sutures. 

Schanz^  placed  five  stout  silk  sutures  between  the  mesial  border  of 
the  patella  and  the  internal  condyle,  on  tying  which  the  capsule  folded 
into  a  sausage-like  roll. 

Delia  A'^edova  ^  recommends  a  plastic  operation  upon  the  lateral  ex- 
pansions by  which  the  outer  one  is  widened,  the  inner  one  narrowed, 
and  a  strip  from  the  side  of  the  ligamentum  patellse  is  detached  and  its 
lower  end  fastened  to  the  side  of  the  internal  condyle  of  the  femur. 

Hildebrand  ^  treated  a  case  by  an  osteotomy  of  the  femur,  giving 
the  knee  the  varus  position. 

1  Potel :  Presse  Med.,  1899,  p.  149. 

2  Albert :  Chirurgie,  vol.  iv.  p.  396. 

3  Eoux:  Eev.  de  Chir.,  August,  1888. 

*  Bradford  :  Boston  Medical  and  Surgical  Journal,  February  20,  1896. 

5  Schanz  :  Zeitschriit  fiir  Orthop.  Chir.,  vol.  vii. 

6  Delia  Vedova  :  Ztlblatt  fiir  Chir.,  1909,  p.  449. 

*  Hildebrand:  Arch,  fiir  klin.  Chir.,  voL  Ixvi.  p.  360. 


CHAPTER  LVI. 

DISLOCATIONS    OF    THE    FIBULA. 

Of  the  Upper  End — Of  the  Lower  End — Spontaneous  or  Pathological. 

The  fibula  may  be  dislocated  at  its  upper  or  at  its  lower  end,  and 
as  the  result  of  external  violence,  or  of  muscular  action,  or  of  unequal 
growth  of  the  tibia  and  fibula. 

DISLOCATIONS  OF  THE  UPPER  END. 

Of  these  there  are  now  about  twenty-five  reported  cases.^  In  the 
majority  the  displacement  was  outward  and  forward,  in  others  back- 
ward, and  in  a  few  upward.  It  is  to  be  remembered  that,  as  the  head 
of  the  fibula  is  situated  behind  the  most  external  part  of  the  tibia,  a 
dislocation  forward  must  also  be  outward. 

Of  cases  complicated  by  fracture  of  either  the  tibia  or  fibula,  or  of 
both  bones,  quite  a  number  have  been  reported.  Of  those  in  which 
the  dislocation  is  produced  by  the  overriding  of  the  fragments  by 
which  the  head  of  the  fibula  is  forced  upward,  it  is  only  necessary  to 
say  that,  although  the  reported  displacement  has  been  very  great  in 
some  cases,  it  does  not  appear  seriously  to  have  affected  the  treatment 
of  the  fracture,  and  in  most  cases  reduction  was  easy.  In  some,  in 
which  the  fracture  united  with  shortening,  there  remained  a  permanent 
displacement  of  the  head  of  the  fibula  upward.  The  dislocation  is 
not  always  upward,  but  is  sometimes  forward,  and  sometimes  the  head 
has  been  freely  movable  backward  and  forward. 

1.  Forward. 

The  cause  has  been  a  fall  with  the  leg  bent  under  the  body  or  a  mus- 
cular effort  without  a  fall,  and  there  is  reason  to  think  that  the  forcible 
depression  and  inversion  of  the  front  of  the  foot  may  be  a  factor  in 
the  production ;  thus,  Savournin's  patient  caught  her  heel  while 
descendiug  a  staircase  and  the  foot  was  sharply  depressed  and  turned 
inward,  and  in  my  two  patients,  one  of  whom  had  not  fallen,  move- 
ment of  the  foot  in  the  direction  mentioned  caused  pain  at  the  site  of 
the  dislocation  after  reduction.  Tillaux,  also,  observed  a  case  of  dias- 
tasis associated  with  fracture  of  the  lower  end  of  the  tibia  (p.  -149). 

The  head  of  the  fibula  can  be  seen  and  felt  in  front  and  outside  of 
its  normal  position,  and  the  tendon  of  the  biceps  shows  plainly  in  an 
unusual  curve.  The  patient  is  usually  unable  to  walk  because  of  pain, 
but  can  move  the  knee  quite  freely. 

1  In  addition  to  the  bibliography  given  in  the  first  edition,  see  Hirschberg,  Arch, 
fiir  klin.  Chir.,  1888,  vol.  xxxvii.  p.  199;  Leggett,  Lancet,  March  31,  1888;  Stimson, 
N.  Y.  Med.  Jour.,  May  25,  1889,  and  Feb.  6,  1892;  Golley,  Am.  Jour.  Surg.  June,  1907. 

62  (  901  ) 


902  DISLOCATIONS. 

Eeduction  has  usually  been  easy  by  direct  pressure  while  the  knee 
was  partly  flexed ;  in  Savouruin's  case  while  the  knee  was  extended 
and  the  foot  in  dorsal  flexion.  I  was  obliged  to  resort  to  arthrotoray 
in  one  case.  Leggett  refers  to  an  unreported  case  in  which  reduction 
failed  two  attem^^ts  having  been  made  under  ansesthesia.  The  obstacle 
in  my  case  appeared  to  be  a  strong  fibrous  band  extending  from  the 
head  of  the  fibula  to  the  front  of  the  tibia ;  after  its  division  reduction 

was  easy. 

2.  Backward. 

In  at  least  one  of  these,  Dubreuil,  the  cause  clearly  seems  to  have 
been  forcible  contraction  of  the  biceps  ;  in  the  others  the  patients  fell, 
and  the  cause  may  have  been  a  twist  of  the  leg  which  ruptured  the 
tibio-fibular  attachments  by  the  pull  of  the  external  lateral  ligament 
of  the  knee,  the  biceps  then  acting  to  displace  the  bone  backward. 

In  two  cases  the  foot  was  slightly  everted,  and  in  one  of  them  there 
was  a  sensation  of  cold  and  numbness  along  the  peroneal  region  of  the 
leg  ;  in  one  the  tendon  of  the  biceps  was  tense.  The  displacement  is 
described  as  backward  in  all,  and  its  extent  as  one  inch  in  Dubreuil's. 

Reduction  was  effected  without  much  difficulty  in  three  by  direct 
pressure  upon  the  head  of  the  fibula  while  the  knee  was  flexed.  In 
Dubreuil's  the  displacement  recurred  on  the  following  day,  and  was 
then  less  easily  reduced ;  a  knee-cap  of  leather  was  then  worn  for 
twelve  days,  and  the  patient  was  then  able  to  walk  with  a  cane,  but 
for  some  lime  the  leg  had  a  tendency  to  bend  outward ;  ultimately 
recovery  was  complete,  as  it  was  also  in  the  other  two  cases. 

Erichsen  and  Oldright  did  not  see  their  patients  until  some  time 
after  the  accident;  in  the  former's  the  displacement  Avas  permanent 
and  the  "limb  was  somewhat  Aveakened,  so  that  the  patient  could  not 
jump,  bat  otherwise  he  suffered  no  inconvenience."  In  Oldright's 
the  displacement  could  be  easily  reduced,  but  it  immediately  recurred  ; 
local  pressure  and  immobilization  of  the  knee  failed  to  cure.  Possibly 
retention  by  a  strip  of  adhesive  plaster  placed  round  the  upper  part  of 
the  les:  would  be  effective. 

3.  Upward.^ 

Of  this  form  there  are  only  three  reported  cases,  Boyer,  Stoll,  and 
Sorbets,  and  the  account  of  the  latter  is  too  incomplete  to  be  of  any 
use  or  even  to  establish  the  accuracy  of  the  diagnosis. 

Boyer's  patient  appears  to  have  received  a  dislocation  outward  of 
the  foot  or  a  Pott's  fracture  of  the  ankle  in  which  the  fibula,  instead 
of  breaking,  had  been  pushed  bodily  upward  ;  the  extent  of  the  dis- 
placement is  not  stated  ;  the  restoration  of  the  foot  to  its  place  cor- 
rected the  upper  dislocation  also,  and  the  patient  recovered. 

In  StoU's  case  the  head  of  the  fibula  is  described  as  standing 
"  notably  higher  than  normal  on  the  outer  surfiice  of  the  tibia,  and 
forming  there  an  immovable,  firm,  sharply  projecting  tumor,  very 
painful  on  pressure."  He  quotes  Dubreuil's  case  as  identical,  and 
attributes  the  displacement  to  the  forcible  contraction  of  the  biceps, 
and,  therefore,  it  seems  possible  that  the  dislocation  may  belong  among 

1  This  is  sometimes  called  "  total "  dislocation,  because  the  lower  end  also  is  displaced. 


DISLOCATIONS  OF  THE  FIBULA.  903 

the  backward  ones.  The  patient  was  a  circus-rider  and  received  the 
injury  in  jumping  from  his  horse,  alighting  upon  his  toes.  The  sole 
was  everted,  the  toes  abducted  ;  the  inner  side  of  the  ankle  swollen 
and  tender  ;  passive  motion  of  the  knee  and  ankle  very  painful ;  numb- 
ness of  the  outer  side  of  the  leg.  No  fracture  could  be  found.  Re- 
duction was  made  by  forcible  traction  on  the  foot,  the  knee  being 
flexed  at  a  right  angle,  and  was  accompanied  by  a  snapping  sound. 

DISLOCATIONS  OF  THE  LOWER  END. 

Of  this  the  only  two  recorded  cases,  excluding,  of  course,  the  innu- 
merable ones  in  which  diastasis  of  this  joint  has  formed  one  of  the  lesions 
of  Pott's  fracture  at  the  ankle  and  the  few  cases  in  which  the  same 
diastasis  has  been  part  of  inward  or  outward  dislocation  of  the  foot, 
are  one  observed  by  Nelaton  in  the  service  of  Gerdy  and  one  in  the 
service  of  Tillaux  reported  by  Dunand.'  Gerdy's  patient  came  to  the 
hospital  thirty-nine  days  after  the  accident.  The  wheel  of  a  wagon 
had  passed  across  the  lower  end  of  his  leg  and  had  forced  the  external 
malleolus  so  far  backward  that  it  was  almost  in  contact  with  the  outer 
border  of  the  tendo  Achillis  ;  the  outer  surface  of  the  astragalus  could 
be  felt  through  almost  its  entire  extent.  The  patient  walked  fairly 
well,  and  Gerdy  thought  no  attempt  to  reduce  should  be  made. 

In  Tillaux's  case  the  patient  in  stepping  from  an  omnibus  caught 
his  foot  and  fell  forward.  The  foot  was  everted,  there  was  a  large 
ecchymosis  on  the  inner  side  of  the  leg  and  foot,  and  another  on  the 
outer  side ;  the  ankle  was  swollen  and  tender,  especially  on  the  inner 
side ;  no  fracture  could  be  found.  The  lower  end  of  the  fibula  was 
freely  movable  forward  and  backward  with  cartilaginous  crepitus, 
and  could  be  drawn  outward  so  far  that  the  end  of  the  finger  could  be 
inserted  between  it  and  the  astragalus.  The  patient  made  a  good 
recovery. 

See  Torini,  in  Clinica  Ifoderna,  1907,  vol.  xiii.,  p.  1037,  for  what 
may  be  another  case. 

I  have  seen  one  case  of  dislocation  backward  from  the  tibia,  possibly 
with  preservation  of  the  relations  with  the  calcaneum.  The  patient, 
a  lad  of  seventeen,  was  admitted  to  the  House  of  Relief,  July  17, 
1889,  having  been  injured  in  the  left  ankle  while  wrestling.  The 
foot  was  abducted,  its  inner  side  normal  and  painless  ;  the  lower  part 
of  the  fibula  was  prominent,  the  region  swollen  and  tender.  A  care- 
ful examination  was  made  under  ether,  and  the  above  diagnosis  reached. 
On  adduction  of  the  front  of  the  foot  the  bone  returned  to  its  ])lace 
with  an  audible  snap.  The  dislocation  was  then  reproduced  by  abduc- 
tion of  the  foot,  and  again  reduced  by  adduction. 

SPONTANEOUS  OR  PATHOLOGICAL  DISLOCATIONS. 

These  have  been  reported  as  occurring  at  the  u])per  end  in  conse- 
quence of  inflammation  of  the  joint,  of  rhachitic  changes  in  the  bones, 
and  of  exaggerated  growth  of  the  tibia  following  necrosis.     In  the 

'  Dunand  :  Thdse  de  Paris,  1878,  No.  217. 


904  DISLOCATIONS. 

same  group  may  be  classed  a  dislocation  outward  reported  by  Bryant, 
which  was  due  to  arrest  of  growth  of  the  tibia. 

Malgaigne,  after  quoting  a  general  description  given  by  Cooper, 
according  to  which  chronic  hydrarthrosis  leads  to  the  easy  displace- 
ment of  the  head  of  the  fibula  and  to  much  weakness  and  fatigue  in 
walking,  describes  a  case  under  his  own  care  in  which  this  laxity  of 
the  joint  existed  ;  in  certain  movements  of  the  knee  the  fibula  was  dis- 
placed backward,  returning  almost  at  once  to  its  place  with  a  cracking 
sound ;  the  condition  followed  an  arthritis  which  had  produced  a  sim- 
ilar relaxation  of  the  knee.  In  a  case  of  rhachitic  curvature  of  the 
leg  in  an  infant  Malgaigne  thought  he  could  recognize  the  head  of  the 
fibula  displaced  upward  almost  to  the  level  of  the  articular  surface  of 
the  tibia,  and  on  examining  the  rhachitic  skeletons  preserved  in  the 
Musee  Dupuytren  he  found  several  examples ;  the  displacement  was 
upward  and  outward  at  the  upper  end,  the  lower  end  preserving  its 
normal  relations. 

Dislocation  downward  of  the  upper  end  due  to  elongation  of  the 
tibia  following  necrosis  was  described  by  Parise  (quoted  by  Malgaigne), 
who  reported  three  cases.  In  one  of  them  the  elongation  was  three 
centimetres  on  the  inner  side  of  the  tibia,  one  and  a  half  centimetres 
on  the  outer.  Malgaigne  subsequently  saw  and  reported  a  fourth 
case.     The  conditions  did  not  affect  the  functions  of  the  limb. 


CHAPTER   LVIL 

DISLOCATIONS  AT  OR  NEAR  THE  ANKLE. 

Dislocations  of  the  Foot  (Tibio-tarsal) — Subastragaloid — Total   Dislocation  of 
the  Astragalus — Medio-tarsal — Congenital. 

Anatomy. 

The  principal  movements  of  the  foot  are  that  of  flexion  and 
extension,  or  dorsal  and  plantar  flexion,  which  takes  place  in  the 
joint  formed  by  the  astragalus  and  the  tibia  and  fibula,  and  that  of 
adduction  and  abduction  combined,  respectively,  with  inversion  and 
aversion  of  the  sole,  which  takes  place  in  the  joints  between  the  astrag- 
alus on  one  side,  and  the  calcaneum  and  scaphoid  on  the  other,  and  is 
aided  by  slight  motion  between  the  calcaneum  and  cuboid.  The  axis 
of  the  first  joint,  the  ankle,  is  horizontal  and  nearly  transverse,  its 
inner  end  inclining  forward ;  that  of  the  other  runs  obliquely  from  a 
point  near  the  inner  tuberosity  of  the  calcaneum  upward  and  forward 
to  a  point  on  the  upper  surface  of  the  neck  of  the  astragalus. 

The  astragalus  articulates  above  with  the  under  surface  of  the  tibia, 
and  on  the  sides  with  the  malleoli,  between  which  it  is  so  snugly  placed 
that  no  lateral  motion  is  possible.  On  each  side  the  lateral  ligament 
passes  to  the  astragalus  and  calcaneum  from  the  malleolus,  and  the 
lower  ends  of  the  tibia  and  fibula  are  bound  together  by  ligaments  in 
front  and  behind.  The  range  of  dorsal  and  plantar  flexion  is  nearly  90 
degrees,  and  as  the  articular  surface  of  the  astragalus  is  somewhat  nar- 
rower behind  than  in  front  some  lateral  motion  of  the  joint  is  possible 
in  full  plantar  flexion. 

The  rounded  head  of  the  astragalus  articulates  with  the  posterior 
concave  surface  of  the  scaphoid,  the  inferior  calcaneo-scaphoid  liga- 
ment, and  slightly  with  the  anterior  end  of  the  calcaneum.  On  the 
under  surface  of  the  astragalus  are  two  articular  facets  corresponding 
to  two  on  the  upper  surface  of  the  calcaneum,  and  between  them  is  the 
strong  interosseous  ligament  which  fills  the  canal  formed  by  a  groove 
on  each  bone  separating  its  two  articular  surfaces,  and  binds  the  bones 
firmly  together.  The  maximum  range  of  motion  in  these  joints  is 
about  40  degrees,  and  is  limited  partly  by  bony  contact  and  partly  by 
the  ligaments. 

In  this  chapter  I  shall  describe  four  different  dislocations  :  those  of 
the  foot,  those  of  the  astragalus,  the  subastragaloid,  and  the  medio- 
tarsal  dislocations ;  under  tiie  first  term  are  included  tliose  in  whicli 
the  astragalus,  while  maintaining  its  relations  with  the  other  bones  of 
the  foot,  is  displaced  from  the  bones  of  the  leg ;  under  the  second, 
those  in  which  it  is  also  displaced  from  the  calcaneum  and  scaplioid  ; 
under  the  third,  those  in  which  the  astragalus  remains  in  tlie  tibio- 

( 905  ) 


906  DISLOCATIONS. 

fibular  mortise  and  is  separated  from  the  calcaneum  and  scaphoid  ;  and 
under  the  fourth,  those  in  which  the  scaphoid  and  cuboid  are  together 
dislocated  from  the  astragalus  and  calcaneum. 

DISLOCATIONS  OF  THE  FOOT.     TIBIO-TARSAL  DISLOCATIONS. 

The  displacements  of  the  astragalus  and  the  foot  are  so  complex 
that  the  nomenclature  of  the  various  dislocations  presents  serious  diffi- 
culties, and  the  confusion  has  been  increased  by  the  varying  practices 
of  different  writers,  some  of  whom  treat  the  tibia  as  the  dislocated  bone 
and  apply  the  terms  indicative  of  direction  to  it,  while  others  consider 
the  foot  as  the  dislocated  portion.  I  shall  here  follow  the  latter  prac- 
tice, and  shall  use  in  the  classification  only  four  main  terms,  disloca- 
tions fonvard,  backward,  outward,  and  inward,  disregarding  for  the 
moment  the  many  deviations  in  the  direction  of  the  toes  and  of  the 
sole  which  are  seen  in  conjunction  with  the  principal  dislocations.  (The 
latter  two  are  sometimes  subdivided  into  four :  jyronation,  supination, 
inversion,  and  eversion  ;  for  the  latter  two  names  adduction  and  abduc- 
tion seem  preferable.)  Of  these  four  the  first  two  are  pure  dislocations ; 
in  the  latter  two  are  frequently  placed  cases  in  which  the  displacement 
is  associated  with  fracture  of  one  or  both  bones  of  the  leg,  and  of 
which  the  more  common  forms  have  been  elsewhere  described  among 
fractures  at  the  ankle.  It  must  be  freely  conceded  that  the  classifica- 
tion, especially  in  respect  of  the  last  two  groups,  is  arbitrary  and  open 
to  serious  criticism,  but  so  are  all  others  that  have  been  proposed,  and 
it  is  believed  that  this  one  has  a  sound  clinical  basis  in  so  far  that  the 
terms  outward  and  inward  correspond  to  displacement  outward,  or 
eversion,  or  to  displacement  inward,  or  inversion  of  the  foot,  the  symp- 
toms which  would  at  once  attract  the  attention  of  the  surgeon,  and  that 
its  divisions  coincide  also  with  those  of  the  modes  of  production.  A 
fifth  group,  dislocation  ujnvard,  between  the  separated  tibia  and  fibula, 
may  be  added. 

Two  striking  varieties,  in  which  the  toes  are  turned  directly  inward 
or  outward,  will  be  mentioned  under  inward  and  outward  dislocations 
respectively.  The  latter  has  been  classified  by  some  as  a  separate 
form,  under  the  title  of  dislocation  of  the  foot  by  rotation  outward. 

The  mechanism  of  the  joint  and  the  mode  of  production  of  the  dis- 
locations have  been  experimentally  studied  by  many  surgeons  and 
anatomists,  of  whom  I  shall  here  name  only  one,  Honigschmied,^ 
whose  experiments  were  exceptionally  numerous  and  whose  article  is 
very  full.  Wendel  ^  collected  108  cases  uncomplicated  by  fracture  re- 
ported before  1898. 

1.  Dislocations  Backward. 

(Syn.  Dislocations  of  the  lower  end  of  the  tibia  forward ;  see  also 
Fractures  at  the  Ankle.) 

In  these  dislocations  the  astragalus,  and  with  it  the  foot,  is  displaced 
backward  to  a  variable  distance,  with  rupture  of  the  lateral  ligaments 

1  Honigschmied :  Deutsche  Zeitschrift  fur  Chir.,  1877,  vol.  viii.  p.  239. 
'  Weudel :  Beitrage  zur  klin.  Chir.,  vol.  xxi.  p. 123. 


DISLOCATIONS  AT  OR  NEAR  THE  ANKLE.  907 

and  sometimes  of  other  parts  of  the  capsule,  and  sometimes  witli  frac- 
ture of  one  or  both  malleoli  or  of  the  posterior  edge  of  the  lower 
articular  surface  of  the  tibia. 

The  cause  is  usually  extreme  plantar  flexion  of  the  foot,  in  which 
the  posterior  border  of  the  end  of  the  tibia  comes  into  contact  with  the 
posterior  lip  of  the  astragalus  (Henke '),  by  which  a  new  centre  of 
motion  is  established  behind  the  line  of  the  malleoli ;  the  continuation 
of  the  movement  ruptures  the  lateral  and  the  anterior  ligaments,  and 
the  bones  being  thus  freed  slip  past  each  other.  The  rupture  of  the 
ligaments  is  the  first  step,  and  the  fixation  of  the  astragalus  behind 
the  tibia  takes  place  by  correction  of  the  plantar  flexion.  Commonly 
the  injury  is  produced  by  a  fall  backward  while  the  foot  is  fixed.  In 
an  incomplete  dislocation  reported  by  Sanson  (quoted  by  Albert)  the 
patient's  leg  was  bent  under  him  in  a  fall  in  such  a  way  that  the  dor- 
sum of  the  foot  and  the  front  of  the  leg  rested  on  the  ground,  and  the 
buttocks  rested  on  the  heel ;  in  this  case  the  mechanism  appears  to  have 
been  pure  exaggerated  plantar  flexion.  Examples  of  pure  primary  dis- 
location are  rare  ;  but  partial,  and  perhaps  complete,  dislocations  occur- 
ring as  a  secondary  result  of  rupture  of  the  lateral  ligaments  or  fracture 
of  the  fibula  and  internal  malleolus,  as  in  fracture  by  eversion  at  the 
ankle,  are  frequent,  and  always  need  to  be  guarded  against  in  the  treat- 
ment of  this  last-named  injury  ;  they  are  produced  either  by  the  falling 
backward  of  the  insufficiently  supported  foot,  as  the  patient  lies  upon  his 
back,  or  by  contraction  of  the  flexor  muscles,  and  occasionally  subcu- 
taneous division  of  the  tendo  Achillis  has  been  resorted  to  to  overcome 
or  prevent  it.  Wendel  collected  26  uncomplicated  cases,  of  which  6 
were  compound. 

Honigschmied  produced  the  dislocation  twenty  times  and  found  the 
results  quite  constant ;  in  14  the  internal  lateral  and  the  anterior  branch 
of  the  external  lateral  ligament  were  the  first  to  yield,  being  torn  away 
from  their  insertions,  then  the  middle  and  posterior  branches  of  the 
external  lateral  ligament  yielded,  and  the  foot  was  thus  completely 
freed.  The  ligaments  were  torn  away,  and  occasionally  small  scales 
of  bone  came  away  with  them.  In  5  experiments  on  the  bodies  of 
elderly  people,  both  malleoli  were  broken  off  in  3,  and  the  external 
malleolus  in  2.  The  internal  malleolus  broke  at  its  base,  and  the  line 
of  fracture  ran  dowuAvard  and  backward ;  that  of  the  external  mal- 
leolus ran  upward  and  backward,  beginning  just  above  the  insertion 
of  the  anterior  branch  of  the  lateral  ligament. 

Clinically  and  post  mortem  the  same  lesions  have  been  found  ;  frac- 
ture of  the  external  malleolus  is  common,  that  of  the  internal  malleolus 
and  of  the  posterior  articular  border  of  the  tibia  is  occasionally  seen. 

The  foot  appears  shortened  in  front,  and  the  heel  lengthened,  to  an 
extent  that  varies  with  the  degree  of  the  displacement,  the  maximum 
being  about  an  inch  ;  the  lower  end  of  the  tibia  projects  more  or  less 
markedly  in  front  and  sometimes  is  exposed  by  rupture  of  the  skin  ; 
the  extensor  tendons  may  be  felt  as  tense  cords  crossing  to  the  dorsum 
of  the  foot,  and  the  tendo  Achillis  curves  backward  to  the  heel  leaving 
on  each  side  a  well-marked  depression  between  itself  and  the  malleolus. 

^  Henke:  Zeitschrift  fiir  rat.  Med. ,1858,  3(1  ser.,  vol.  ii.  p.  177. 


908  DISLOCA  TIONS. 

The  toes  may  be  a  little  depressed,  and  perhaps  abducted  or  adducted. 
If  the  fibula  is  broken  its  malleolus  accompanies  the  foot  in  its  dis- 
placement backward. 

Reduction,  with  the  exception  of  Cooper's  first  case,  in  which  he 
appears  not  to  have  made  the  diagnosis  at  the  time,  has  always  been 
easily  obtained  by  pressing  the  foot  forward  and  the  lower  end  of  the 
leg  backward,  and  the  limb  should  then  be  immobilized,  preferably  in 
a  posterior  moulded  splint  so  as  more  surely  to  prevent  recurrence. 
Statzer  ^  reduced  one  that  was  nine  weeks  old  ;  the  internal  malleolus  was 
broken. 

2.  Dislocations  Forward. 

(Syn.  Dislocations  of  the  lower  end  of  the  tibia  backward.) 

In  this  dislocation,  which  is  much  rarer  than  the  prece*ding,  the 
astragalus,  and  with  it  the  foot,  is  displaced  forward  from  beneath  the 
tibia.  Malgaigne  collected  only  five  cases,  Delamotte,  Colles,  Nela- 
ton,  Pierre,  and  R.  W.  Smith,  and  I  added  in  1888  five  more,  Huguier,^ 
Sarazin,^  Augarde,^  Willemin,"*  and  Hornby ,6  making  ten  in  all.  Wen- 
del  collected  11  cases,  6  of  which  are  new. 

The  mode  of  production  may  be  by  dorsal  flexion  of  the  foot  fol- 
lowed by  impulsion  of  the  tibia  downward  and  backward  by  a  force 
acting  in  the  direction  of  its  long  axis,  or  by  direct  pressure  of  the 
foot  forward  and  of  the  leg  backward  while  they  are  at  right  angles  to 
each  other.  Among  the  recorded  cases  are  clear  examples  of  each, 
such  as  R.  AV.  Smith's  and  Nekton's  of  the  former,  and  Huguier's 
of  the  latter.  R.  W.  Smith's '^  patient,  while  standing  with  the  hip 
and  knee  flexed  and  with  the  foot  resting  on  a  stone  in  such  a  manner 
tiiat  the  toes  were  higher  than  the  heel,  was  struck  upon  the  knee  by 
a  falling  cask  which  forced  it  downward  and  increased  the  flexion  at  the 
knee  and  ankle.  In  Nelaton's  case,^  a  woman,  who  fell  from  the 
fourth  floor,  the  anterior  lip  of  the  articular  surface  of  the  tibia  was 
broken  off,  and  the  upper  surface  of  the  astragalus  was  scratched 
antero-posteriorly. 

In  the  second  method  of  production  the  force  and  counter-force  act 
at  right  angles  to  the  long  axis  of  the  limb,  the  one  upon  the  front  of 
the  lower  end  of  the  tibia,  the  other  in  the  opposite  direction  upon  the 
back  of  the  heel.  Huguier's  case  is  an  example  :  a  man,  while  engaged 
in  turning  a  railway  turntable,  fell  and  caught  his  foot  in  such  a  man- 
ner that  the  heel  was  fixed  and  a  projecting  rail  wn  the  moving  turn- 
table pressed  against  the  front  of  the  tibia  six  inches  above  the  ankle 
and  produced  a  well-marked  dislocation  of  the  foot  forward. 

The  symptoms  are  lengthening  of  the  front  of  the  foot  and  shorten- 
ing of  the  heel,  with  effacement  of  the  depressions  on  each  side  of  the 

1  Statzer :  Wiener  kliii.  Wochenschrift,  1904,  No.  3. 

*  Huguier  :  Gaz.  des  Hopitaux,  1855,  p.  469,  and  Arch.  gen.  de  Med.,  1868,  vol.  i.  p.  513 
^  Sarazin  :  Recueil  de  mem.  de  med.  chir.  et  pharm.  mil.,  1860,  vol.  iv.  p.  66. 

*  Augarde:  Idem,  1880,  vol.  xxxvi.  p.  168. 

5  Willemin  :  L'Union  med.,  1866,  vol.  xxix.  pp.  50  and  73. 

*  Hornby:  Medical  Times  and  Gazette,  1871,  vol.  ii.  p.  10. 

'  R.  W.  Smith:  Dublin  Quarterly  Journal  of  Medicine,  1852,  vol.  1.  p.  465. 
8  Nelaton :  Pathol,  externe,  vol.  ii.  p.  477. 


DISLOCATIONS  AT  OR  NEAR   THE  ANKLE.  909 

tendo  Achillis.  The  foot  is  in  the  position  of  more  or  less  plantar 
flexion,  and  in  one  or  two  cases  tlie  hollow  of  the  instep  was  exagger- 
ated. The  npper  articular  surface  of  the  astragalus  can  be  felt  in  front 
of  the  end  of  the  tibia,  and  the  malleoli  are  nearer  to  the  heel  and  to 
the  sole  than  normal. 

In  four  cases  reduction  was  easily  made  by  traction  and  direct  ])ress- 
ure ;  in  Smith's  it  could  not  be  made,  but  there  is  reason  to  think  the 
efforts  were  not  guided  by  a  correct  appreciation  of  the  nature  of  the 
injury  ;  jN^elaton's  patient  was  killed  by  the  fall ;  in  the  remaining  cases 
the  details  of  treatment  are  lacking. 

3.  Dislocations  Inward. 

In  this  division  are  placed  those  cases  in  which,  usually  by  adduction 
and  inversion  (supination),  the  foot  is  moved  downward  and  to  the 
inner  side,  so  that  the  astragalus  leaves  the  tibio-fibular  mortise  more 
or  less  completely.  Two  distinct  forms  are  observed  :  in  one  the  foot 
is  markedly  inverted  and  the  upper  surface  of  the  astragalus  can  be 
seen  and  felt  raising  the  skin  under  the  external  malleolus ;  in  the 
other  the  inversion  of  the  foot  is  less  or  is  absent  and  there  is  marked 
adduction,  so  that  sometimes  the  ends  of  the  toes  point  directly  inward  ; 
in  the  latter  form  it  is  thought  that  the  displacement  is  secondary  to  a 
backward  dislocation.  If  the  two  forms  are  separated  the  former  is 
called  supination,  the  latter  adduction  or  inversion  dislocation.  Wen- 
del's  list  contains  36  supination  (22  compound)  and  3  adduction  (2 
compound). 

Malgaigne  includes  in  the  group  (which  he  terms  tibio-tarsal  dislo- 
cations outward)  many  cases  complicated  by  fracture  of  the  astragalus 
or  of  one  or  both  bones  of  the  leg ;  but  of  his  total  of  22  cases,  8  were 
not  thus  complicated,  and  to  these  I  can  add  5,  Busch,^  Nunnely,^ 
Eames,^  Carmichael,*  and  Spaeth.^  I  have  described  under  "  frac- 
tures by  inversion  and  adduction  of  the  foot"  the  lesions  and  symp- 
toms in  cases  in  which  fracture  is  present  and  the  displacement  is  slight. 

Excluding  for  the  moment  those  cases  in  which  the  displacement  is 
secondary  to  a  backward  dislocation,  it  seems  probable  that  the  cause 
is  violent  supination,  or  inversion,  of  the  foot,  but  the  histories  of  the 
cases  do  not  positively  establish  this  opinion.  In  most  the  cause  has 
been  a  fall,  usually  from  a  height. 

The  astragalus  fits  so  snugly  and  squarely  into  the  tibio-fibular  mor- 
tise that  in  a  considerable  proportion  of  cases  its  turn  about  its  antero- 
posterior axis  breaks  the  external  malleolus  or  forces  it  away  from  the 
tibia  by  the  pressure  of  the  upper  outer  edge  of  the  astragalus.  In  the 
experiments  which  Honigschmied  made  by  fixing  the  foot  in  a  vise  and 
bending  the  leg  directly  toward  the  inner  side — tibial  fiexion — the 
external  malleolus  was  broken  5  times,  the  external  lateral  ligament 
torn  from  its  insertion  12  times,  and  in  3  cases  the  joint  remained 
unopened  and  separation  took  place  between  the  astragalus  and  the 

1  Bnsch  :  Lehrbucli  dcr  Chir.,  vol.  ii.,  part  3,  p.  327;  quoted  by  Lossen. 

2  Nuiinely:  Britisli  Mcdiciil  .Tonrnal,  1868,  vol.  ii.  p.  362. 

»  Eanies :"  Idem,  1H71,  vol.  i.  p.  503.  *  Oarmichael :  Idem,  1871,  vol.  ii.  p.  S."). 

*  Spaeth  :  Miinchen.  mod.  Wochen.,  .January  17,  1888. 


910  DISLOCATIONS. 

calcaneum.  These  results  coincide  in  the  main  with  those  obtained  in 
a  similar  manner  by  Bonnet,  and  Honigschmied  accepts  the  latter's 
opinion  that  the  fracture  of  the  malleolus  is  effected  by  the  direct  press- 
ure upon  it  of  the  outer  upper  border  of  the  astragalus  and  not  by  trac- 
tion exerted  through  the  external  lateral  ligament.  Bonnet  frequently 
found  the  internal  malleolus  also  broken,  Honigschmeid  never. 

In  one  case,  Busch,  in  which  there  was  no  fracture,  the  dislocation 
was  compound  and  the  bones  of  the  leg  protruded  through  the  wound 
in  front,  the  astragalus  lay  entirely  to  the  inner  side  of  the  internal 
malleolus,  and  the  foot  was  greatly  adducted ;  Busch  thought  the  dis- 
location had  been  primarily  backward.  Of  Wendel's  22  compound 
cases  the  bones  protruded  iu  16;  15  were  reduced,  5  after  resection; 
one  of  these  died,  the  others  made  slow  recoveries  with  useful  joints. 

In  some  caseSj  in  which  the  displacement  inward  may  be  assumed  to 
have  been  secondary  to  a  backward  dislocation,  the  adduction  of  the 
foot  has  been  very  great,  90  degrees,  so  that  the  toes  pointed  directly 
toward  the  other  ankle ;  in  the  others  the  adduction  is  less,  but  the 
inversion  is  great ;  in  Carmichael's  "  the  plantar  aspect  pointed  to  the 
middle  line  of  the  body,"  in  Eames's  "  the  plantar  aspect  of  the  foot 
was  completely  inverted,"  in  Spaeth's  the  inner  border  lay  directly 
beneath  the  tibia.  In  some  the  external  malleolus  was  very  promi- 
nent ;  in  Nunnely's  "  there  was  a  large  and  well  marked  projection 
below  the  outer  malleolus  "  over  which  the  skin  was  very  tense,  and 
"  there  was  a  deep,  narrow  depression  at  the  inner  malleolus  where  the 
skin  was  also  very  tight." 

Keduction  has  always  been  easily  effected  by  traction  and  e version 
of  the  foot,  and  in  the  uncomplicated  cases  the  recovery  has  been 
complete. 

4.  Dislocations  Outward. 

Most  of  the  displacements  reported  under  this  title  have  been  inci- 
dental to  fracture  by  eversion  and  abduction  of  the  foot  (Chapter  XXV.). 
But  Wendel  collected  27  uncomplicated  by  fracture,  grouping  them  as 
19  pronation  and  8  eversion  dislocations.  Of  the  19,  14  were  com- 
pound. The  sole  is  everted,  sometimes  looking  almost  directly  upward  ; 
the  astragalus  lies  under  the  internal  malleolus,  or  obliquely  across  the 
mortise,  or,  iu  compound  cases,  may  be  external  to  the  external  mal- 
leolus. The  malleoli  are  separated.  The  5  simple  cases  were  reduced 
and  made  good  recoveries.  Of  the  14  compound  the  tibia  projected 
through  the  wound  in  6  ;  all  were  reduced,  4  after  resection  ;  1  death. 

In  four  cases,  Huguier,^  Thomas,^  Soubie,^  and  Knust,^  the  foot  has 
been  so  far  abducted  that  the  toes  pointed  directly  outward.  Wendel 
collected  8.  This  form  was  first  observed  by  Huguier  and  described 
by  him  as  "  dislocation  of  the  foot  by  rotation  outwai'd."  His  patient 
was  overthrown  by  a  cask,  which  rolled  upon  his  legs  ;  Thomas's  by  a 
falling  mass  of  straw  ;  Soubie's  fell  from  a  height  of  six  feet,  alighting 
upon  his  left  foot,  which  was  then  engaged  between  a  large  stone  and 

'  Huguier:  L' Union  Medicale,  1848,  p.  128. 

2  Thomas:  Revue  de  Chirurgie,  1887,  p.  821. 

^  Soubie  :  Quoted  by  Thomas. 

*  Knust:  Centralblatt  fiir  Chirurgie,  1898,  p.  320. 


DISLOCATIONS  AT  OR  NEAR  THE  ANKLE.  911 

the  trunk  of  a  vine  while  the  body  was  twisted  to  the  right,  and  the 
patient  fell  on  his  right  side  ;  and  Knust's  twisted  his  right  foot  in  like 
manner,  the  body  turning  to  the  left.  In  Huguier's  case  the  external 
malleolus  was  separated  from  the  tibia,  pressed  backward,  and  rotated 
outward,  and  the  shaft  of  the  fibula  was  broken  in  the  upper  third. 
In  the  other  two  cases  no  fracture  was  found.  Reduction  was  easily 
effected  under  anaesthesia  in  the  first  three  cases ;  not  mentioned  in 
the  fourth. 

In  January,  1904,  I  saw  at  the  Hudson  Street  Hospital  a  man  forty 
years  old  who  had  injured  his  right  ankle  by  slipping  on  the  sidewalk 
an  hour  previously.  The  foot  was  abducted  nearly  90  degrees,  and 
over  the  internal  malleolus  the  skin  was  tightly  stretched,  and  almost 
the  entire  articular  surface  of  the  tibia  could  be  easily  palpated.  The 
fibula  was  separated  from  the  tibia  below  and  pushed  backward  by  the 
foot ;  it  was  broken  at  the  middle,  without  displacement.  Reduction 
was  easy  by  traction  and  adduction  of  the  foot.  Schubert  ^  reports  two 
similar  cases  with  fracture  of  the  fibula  at  the  upper  end. 

5.  Dislocation  Upward. 

In  this  the  astragalus  is  displaced  upward  between  the  malleoli. 
Wendel  collected  four  cases,  but  he  gives  few  details  and  I  have  been 
able  to  consult  the  original  report  of  only  two.^  The  usual  cause  was 
a  fall  upon  the  foot ;  none  was  compound ;  reduction  was  easily  made, 
and  the  result  in  the  three  cases  in  which  it  was  known  was  good. 

6.  Compound  and  Complicated  Dislocations  of  the  Foot. 

Dislocations  of  the  foot  may  be  compound,  primarily  or  secondarily, 
with  prolusion  of  the  bones  of  the  leg  or  of  the  astragalus  through 
the  wound,  and  they  may  be  complicated  by  rupture  of  bloodvessels 
and  by  other  fractures  than  those  of  the  malleoli  already  referred  to. 

In  dislocations  that  are  primarily  compound  the  wound  of  the  skin 
may  be  made  from  within  outward  by  the  projecting  bone  or  by  contact 
with  the  ground.  In  those  that  become  secondarily  compound  the 
sloughing  of  the  soft  parts  may  be  due  to  the  pressure  of  the  unre- 
duced bones  or  to  bruising  of  the  soft  parts  inflicted  at  the  time  of 
dislocation. 

Statistics  that  have  been  collected  from  the  period  anterior  to  the 
introduction  of  antiseptic  methods  cannot  be  trusted  to  show  the  neces- 
sity or  desirability  of  amputation  or  excision.  Later  ones  (Scudder^) 
show  that  conservative  treatment  may  be  safely  tried  in  many  cases. 
Amputation  or  excision  is  indicated  when  infection  is  certain,  the 
patient  feeble,  or  the  functional  result  otherwise  likely  to  be  bad. 
Neither  the  loss  of  the  astragalus  nor  anchylosis  of  the  ankle-joint 
usually  causes  much  disability.  Particular  attention  must  be  given 
to  drainage,  and  as  the  astragalus  completely  fills  the  space  between 

1  Schubert :  Deutsche  Zeitschrift  fur  Chir.,  1904,  vol.  Ixxii.  p.  396. 

2  Lancet,  1856,  ii.  p.  60. 

3  Scudder  :  Boston  Medical  and  Surgical  Journal,  April  7,  1892. 


912  DISLOCATIONS. 

the  malleoli  separate  drainage  must  l)e  provided  for  the  back  and  front 
of  the  joint. 

The  limb  must  be  carefully  immobilized  with  the  foot  at  a  right 
angle  to  the  leg  and  without  inversion  or  eversion,  in  order  that  if  the 
joint  should  become  stiff  the  disability  will  not  be  increased  by  a 
faulty  position  of  the  foot. 

SUBASTRAGALOID  DISLOCATIONS.  DISLOOATON  OF  THE  AS- 
TRAGALO-CALCANEOID  AND  THE  ASTRAGALO-SCAPHOID 
JOINTS. 

For  the  establishment  of  this  group  in  the  classification  of  disloca- 
tions of  the  tarsal  bones  we  are  indebted  to  Broca/  who,  in  a  remark- 
able paper  read  before  the  Societe  de  Chirurgie  in  1852,  carefully 
analvzed  the  scattered  cases  that  had  been  reported  under  various  titles 
and  gave  a  detailed  and  systematic  description  of  the  various  forms  of 
the  injury,  to  which  little  has  since  been  added  except  in  amplification 
of  the  statistics.  His  plan  of  subdivision  recognized  dislocations  back- 
ward, inw^ard,  and  outward  of  the  calcaneum  and  scaphoid  from  the 
astragalus.  Malgaigne  added  a  fourth  variety,  dislocations  forward, 
and  changed  the  nomenclature  by  treating  the  astragalus  as  the  dislo- 
cated bone  and  applying  the  terms  indicative  of  the  direction  of  the 
displacement  according  to  its  position  with  relation  to  the  others.  I 
shall  here  follow  Broca's  use  of  the  terms,  which  is  in  harmony  with 
that  used  in  the  other  dislocations. 

The  dislocation,  then,  presents  four  varieties  :  that  in  which  the  cal- 
caneum and  scaphoid  are  displaced  inward  (and  somewhat  backward). 
the  head  of  the  astragalus  projecting  on  the  outer  part  of  the  dorsum 
of  the  foot ;  that  in  which  they  are  displaced  outward ;  and  those  in 
which  thev  are  displaced  directly  forward  or  backward  and  downward. 
The  first  two  are  about  equal  in  frequency  and  together  comjjrise  most 
of  the  reported  cases;  of  each  of  the  last  two  only  one  or  two  exam- 
ples have  been  reported.  The  most  notable  addition  to  the  collected 
statistics  has  been  made  by  Poinsot.^ 

1,  Dislocations  Inward,  or  Inward  and  Backward. 

The  cause  is  forcible  inversion  and  adduction  of  the  foot,  usually 
combined  with  violence  acting  in  the  direction  of  the  long  axis  of  the 
leg,  as  in  a  fall  from  a  height.  The  displacement  is  rarely,  if  ever, 
directly  inward,  but  is  also  somewhat  backward,  so  that  the  head  of 
the  astragalus  rests  partly  upon  the  cuboid.  The  only  autopsy  is  one 
made  in  an  old  case  by  Quenu  ;^  there  was  shortening  of  the  dorsum 
of  the  foot  and  elongation  of  the  heel,  and  the  foot  was  in  the  position 
of  varus.  The  head  of  the  astragalus  lay  upon  the  interarticular  lines 
between  the  calcaneum  and  cuboid  and  the  cuboid  and  scaphoid,  over- 

^  Broca :  Mem.  de  la  Soc.  de  Chirurgie.  1852,  vol.  iii.  p.  566,  and  abstract  in  Bull,  de  la 
Soc.  de  Chirurgie,  1853,  vol.  iii.  p.  241. 

^  Poinsot :  L' intervention  chirurgicale  dans  les  luxations  compliquees  du  cou-de-pied, 
Paris,  1877,  and  his  translation  of  Hamilton's  Fractures  and  Dislocations,  p.  1196. 

3  Quenu  :  Progres  Med.,  1883,  p.  187. 


PLATE  XXXIX 


Subastragaloid  Dislocation. 


DISLOCATIONS  AT  OR  NEAR   THE  ANKLE. 


913 


lapping  the  former  half  an  inch  and  thus  resting  on  the  cuboid.  The 
posterior  border  of  the  astragalus  hxy  in  the  groove  betM'een  the  anterior 
and  posterior  superior  articular  surfaces  of  the  calcaueum,  and  its  pos- 
terior lip  had  been  broken  oflP  and  remained  in  its  normal  relations  with 
the  calcaneum.  There  was  no  fracture  of  either  malleolus.  The  dorsalis 
pedis  artery  and  the  extensor  tendons  lay  to  the  inner  side  of  the  head 
of  the  astragalus ;  the  peroneal  tendons  had  been  displaced  from  their 
groove  and  separated  half  an  inch  from  the  fibula.  In  other  cases  the 
displacement  has  been  greater  and  the  skin  has  been  broken  on  the 
outer  side  of  the  foot ;  in  one  of  Malgaigne's  the  head  of  the  astragalus 


Fig.  4 

74. 

HT 

'^■"^M 

■ 

Bi 

w] 

H 

^^^^^W         "^^1 

H 

H^p    M^Mt^ 

? 

!S: 

^m 

^2 

^\/'" 

\ 

-J 

1 

^^Hk 

m 
1^ 

3 

Subastragaloid  dislocation  inward. 


was  ahnost  in  contact  with  the  fifth  metatarsal  bone;  in  one  of  Leten- 
neur's  it  corresponded  to  the  outer  border  of  the  foot  and  projected 
entirely  through  a  wound  in  the  skin,  and  the  calcaneum  had  been  com- 
pletely displaced  from  its  inferior  articular  surface.  In  one  of  my  own 
the  external  malleolus  protruded  through  and  was  tightly  grasped  by 
a  rent  in  the  skin  ;  evidently  perforation  had  occurred  while  the  foot 
was  in  extreme  inversion,  and  I  was  obliged  to  lengthen  the  opening 
downward  for  an  inch  in  order  to  reduce.  The  patient  made  a  good 
recovery,  with  some  limitation  of  inversion  (supination)  of  the  foot, 
Tlie  form  and  degree  of  the  displacement  vary  with  the  different  com- 
binations of  displacement  inward,  backward,  and  by  adduction  of  the 


914 


DISLOCATIONS. 


front  of  the  foot,  the  latter  sometimes  leaving  the  posterior  part  of 
the  calcaneum  less  displaced  inward  than  its  front  part.  With  the 
dislocation  there  are  sometimes  associated  injury  to  the  calcaneo- 
cuboid joint,  rupture  of  its  ligaments,  and  partial  dislocation  of  the 
bones. 

The  symptoms  are  more  or  less  shortening  of  the  dorsum  of  the  foot 
and  lengthening  of  the  heel,  adduction  of  the  toes,  and  elevation  of 
the  inner  border  of  the  foot ;  prominence  of  the  tip  of  the  external 
malleolus  and  of  the  head  of  the  astragalus  on  the  outer  side  of  the 
dorsum,  with  marked  depressibility  of  the  soft  parts  below  each ;  the 
internal  malleolus  is  deeply  placed  under  the  skin,  and  below  and 
behind  it  can  be  felt  the  projecting  sustentaculum  tali,  and  in  front  of 
it  the  inner  surface  of  the  scaphoid. 


Fig.  475. 


2.  Dislocations  Outward. 

Of  these  Malgaigne  makes  two  varieties,  distinguished  clinically  by 
the  existence  of  marked  abduction  of  the  toes 
in  one,  and  its  absence  in  the  other.  In  the 
former  (his  luxation  oblique  en  dedans,  or  obliquely 
outward,  according  to  the  nomenclature  here 
used)  the  posterior  articular  surface  of  the 
astragalus  is  not  separated  from  the  calcaneum, 
but  the  foot  has  turned  upon  the  posterior  cal- 
caneo-astragaloid  joint,  or  upon  the  outer  part 
of  the  interosseous  ligament  as  a  centre,  and 
the  scaphoid  has  been  carried  to  the  outer  side 
of  the  head  of  the  astragalus,  and  also  some- 
limes  either  upward  or  downward.  In  the  sec- 
ond form,  that  without  abduction  of  the  toes, 
I  he  foot  is  displaced  bodily  outward  from  be- 
neath and  in  front  of  the  astragalus.  The 
cause  in  the  former  is  forcible  abduction  of  the 
foot ;  in  the  latter  it  appears  to  be  either  abduc- 
tion and  eversion  of  the  foot,  or  great  violence 
exerted  directly  against  the  inner  side  of  the 
foot,  or  the  outer  side  of  the  lower  part  of  the 
leg.  The  dislocation  may  be  primarily  or  sec- 
ondarily compound,  the  wound  in  the  skin  cor- 
responding to  the  head  of  the  astragalus  which 
may  project  entirely  through  it.  The  tendon 
of  the  tibialis  anticus  sometimes  lies  along  the 
inner  and  upper  part  of  the  neck  of  the  astrag- 
alus, which  is  thus  tightly  held  between  it  and 
the  calcaneo-scaphoid  ligament.  In  a  case  ot  the  oblique  form  quoted 
by  Malgaigne,  in  which  the  patient  died  four  days  after  the  acci- 
dent, the  outer  part  of  the  interosseous  ligament  in  the  sinus  tarsi  was 
entire  ;  the  inner  part  was  ruptured.  In  one  of  the  complete  outward 
form,  of  which  the  specimen  was  dissected,  and  reported  by  Nelaton ' 
1  Nelaton :  Bull,  de  la  Soc.  Anatomique,  1835,  p.  38. 


Subastragaloid  dislocation 
outward.    (Malgaigne.) 


DISLOCATIONS  AT  OR  NEAR   THE  ANKLE.  915 

(Fig.  475),  the  head  of  the  astragalus  rested  against  the  inner  side  of 
the  scaphoid,  and  its  posterior  lip  was  engaged  in  the  groove  in  the 
upper  surface  of  the  calcaneum  ;  the  lower  part  of  the  internal  lateral 
ligament,  the  interosseous  ligament,  and  the  astragalo-scaphoid  liga- 
ment were  ruptured,  and  the  posterior  and  outer  part  of  the  external 
malleolus  was  broken. 

The  calcaneo-cuboid  joint  may  also  be  injured,  and  the  bones  partly 
displaced  from  each  other. 

The  symptoms  in  the  oblique  variety  are  the  marked  abduction  of 
the  foot,  more  or  less  eversion,  and  marked  prominence  of  the  head  of 
the  astragalus  on  the  inner  side ;  the  head  is  sometimes  so  depressed 
that  the  condition  may  be  mistaken  for  inward  dislocation  of  the 
astragalus.  In  a  case  reported  by  Boyer  the  displacement  was  slight, 
and  was  at  first  overlooked ;  when  recognized,  it  was  irreducible,  but 
the  patient  regained  good  use  of  the  limb. 

The  symptoms  in  the  variety  in  which  the  displacement  is  directly 
outward  are  the  marked  displacement  of  the  foot,  with  but  little,  if 
any,  eversion  or  abduction,  the  axis  of  the  log  falling  to  the  inner  side, 
and  somewhat  in  front  of  the  part  of  the  foot  to  which  it  normally 
corresponds.  Above  the  outer  surface  of  the  calcaneum  and  cuboid 
is  a  notable  depression  in  the  place  of  the  usual  prominences  formed 
by  the  external  malleolus  and  the  head  of  the  astragalus.  The  inter- 
nal malleolus  is  very  prominent  and  nearer  to  the  level  of  the  sole, 
and  below  and  in  front  of  it  is  the  projecting  head  of  the  astragalus, 
On  the  dorsum  of  the  foot  the  scaphoid  is  recognizable  with  a  depression 
behind  it. 

3.  Dislocation  Backward. 

In  this  the  calcaneum  and  scaphoid  are  displaced  directly  backward, 
the  scaphoid  descending  to  a  lower  level  so  as  to  lie  under  the  head  or 
neck  of  the  astragalus.  Deviation  of  the  foot  to  either  side  would 
create  forms  intermediate  between  this  and  the  two  preceding  ones.  A 
number  of  reported  cases,  which  were  claimed  to  be  subluxations  of 
this  kind,  the  relations  between  the  scaphoid  and  astragalus  being 
changed  while  those  between  the  calcaneum  and  astragalus  remained 
unchanged,  were  rejected  by  Broca  as  errors  of  diagnosis,  but  are 
accepted  by  Malgaigne  as  probably  correct.  In  some  of  them  reduc- 
tion was  easy;  in  others  it  failed,  but  the  persistence  of  the  displace- 
ment did  not  permanently  impair  the  functions  of  the  limb. 

Of  the  complete  form  there  are  only  two  recorded  examples  :  the 
first  is  the  much  quoted  case  of  Prof.  Carmichael,  reported  by  Mac- 
donald.^  Carmichael,  in  his  effort  to  avoid  a  fall  when  his  horse 
stumbled  and  came  upon  his  knees,  leaned  back  in  tiie  saddle  and 
thrust  his  feet  forward  ;  his  weight  Avas  received  ujion  the  inner  side 
of  the  ball  of  the  right  foot,  and  tlie  dislocation  was  thereby  produced, 
the  deformity  being  so  great  that  it  was  recognizable  through  his  boot. 
The  toes  were  abducted  about  30  degrees,  the  foot  slightly  everted  ; 
the  concavity  of  the  tendo  Achillis  was  manifestly  increased  and  the 
heel  lengthened  ;    the  astragalus  could  not    be  felt  behind    the  tibia. 

1  Macdouald  :  Dubliu  Quarterly  Journal  Med.  Sci.,  1838,  vol.  xiv.  p.  235. 
63 


QIQ  *  DISLOCATIONS. 

Below  and  in  front  uf  the  inner  malleolus  was  a  hard  prominence,  over 
which  the  skin  was  tense,  formed  by  the  inner  surface  of  the  astragalus. 
The  most  striking  deformity  was  a  prominence  on  the  dorsum  of  the 
foot;  ''immediately  in  front  of  the  tibia  it  presented  a  Hat  surface 
broad  enough  to  receive  the  finger,  from  which  there  was  an  abrupt 
descent  upon  the  anterior  part  of  the  tarsus.  Over  the  projection 
caused  by  the  head  of  the  astragalus  thrown  on  the  upper  surface  of 
the  scaphoid  and  cuneiform  bones,  the  integuments  were  so  tense  that 
it  was  very  evident  a  small  additional  force  would  have  driven  it 
through  the  skin,"  The  distance  from  the  internal  malleolus  to  the 
end  of  the  great  toe  was  one  inch  less  than  on  the  other  foot  No 
fracture  could  be  found.  Flexion  and  extension  were  very  painful. 
The  dislocation  was  reduced  by  traction  with  the  pulleys  and  direct 
pressure  on  the  heel  and  leg. 

The  second  case  was  observed  by  Thierry,  and  communicated  to 
Malgaigne  by  Broca ;  the  dislocation  was  caused  by  a  fall  upon  the 
toes;  the  head  of  the  astragalus  was  prominent  under  the  skin,  the 
front  of  the  foot  appeared  shortened,  the  heel  lengthened  ;  the  foot  M'as 
extended,  and  not  deviated  to  either  side.     Good  recovery. 

An  irregular  case  of  subastragaloid  dislocation  backward  and  out- 
ward in  which  the  scaphoid  preserved  its  relations  Avith  the  astragalus 
and  the  anterior  portion  of  the  line  of  dislocation  ran  between  the 
scaphoid  and  cuneiform  bones  was  reported  by  Kaufmann.^  The  dis- 
placement had  existed  nine  months  and  was  then  treated  by  excision 
of  the  scaphoid  and  head  of  the  astragalus  with  a  good  result. 

4,  Dislocation  Forward. 

Of  this  only  two  cases  uncomplicated  by  fracture  have  been  reported, 
one  by  Parise,  quoted  by  Malgaigne,  the  other  by  Broca,^  Planteau's 
report  {Gaz.  Med.  de  Paris,  1879,  No.  30),  sometimes  quoted  as  a 
third  case,  is  of  Broca's.  Parise's  patient  was  injured  by  being 
crushed  under  a  heavy  weight,  the  thigh  being  flexed  on  the  trunk, 
the  leg  on  the  thigh,  and  the  foot  on  the  leg  (dorsal  flexion).  Nine 
months  afterward  the  condition  was  as  follows  :  the  foot  was  at  a  right 
angle  with  the  leg,  a  little  adducted,  and  very  slightly  everted  ;  it 
was  displaced  forward,  so  that  it  appeared  lengthened  in  front,  and 
the  external  malleolus  almost  touched  the  teudo  Achillis.  The  ex- 
tensor tendons  on  the  instep  were  tense,  and  no  prominence  could  be 
felt  beneath  them,  but  on  the  outer  side  a  bony  prominence  could  be 
felt,  which  was  thought  to  be  the  head  of  the  astragalus,  and  imme- 
diately in  front  was  a  depression  which  admitted  the  finger.  The 
hollow  between  the  astragalus  and  calcaneum  seemed  to  be  tilled. 
Behind,  the  prominence  of  the  heel  was  completely  lost,  the  leg  flat- 
tened, and  its  surface  interrupted  at  the  level  of  and  a  little  below 
the  malleoli  by  a  bony  prominence  which  raised  the  tendo  Achillis 
and  overlapped  the  heel  nearly  half  an  inch ;  above  it  was  another, 
less  prominent,   formed   by  the  posterior  articular  edge  of  the   tibia. 

1  Kaufinann  :  Centralblatt  fiir  Cliir.,  1888,  p.  369. 

'  Broca :  Eeport  by  Petit  of  a  clinical  lecture,  Gaz.  Hebdom.,  1874,  p.  316. 


DISLOCATIONS  AT  OR  NEAR   THE  ANKLE.  917 

There  was  no  trace  of  fracture,  no  separation  of  the  malleoli.  There 
was  slight  motion  in  the  tibio-tarsal  joint ;  motion  in  the  joints  of  the 
tarsus  was  entirely  lost.  The  patient  could  hardly  walk  without 
crutches. 

In  Broca's  case  the  displacement  was  much  less  marked,  and  the 
only  symptoms  were  an  increase  of  one  centimetre  in  the  distance  from 
the  internal  malleolus  to  the  great  toe,  and  a  corresponding  shortening 
of  the  heel,  and  the  absence  of  abnormal  prominence  of  the  astragalus 
in  front  of  the  tibia.  By  traction  and  pressure  under  chloroform  the  in- 
equality in  the  measurements  was  overcome  and  the  patient,  at  the  time 
of  the  report,  was  in  a  fair  way  to  recover.  So  far  as  can  be  judged 
from  the  re})ort,  Broca  did  not  consider  the  diagnosis  entirely  clear,  and 
the  symptoms  as  given  are  identical  with  those  of  Sarazin's  case  of 
incomplete  tibio-tarsal  dislocation  forward.  The  differential  diagnosis 
between  these  two  injuries  would  have  to  be  made  on  the  existence  of 
a  gap  between  the  astragalus  and  scaphoid  in  the  subastragaloid  dislo- 
cation, and  the  absence  of  such  a  gap  and  possibly  the  abnormal  promi- 
nence of  the  upper  articular  surface  of  the  astragalus  in  front  of  the 
tibia  in  the  incomplete  tibio-tarsal  dislocation  forward.  The  recogni- 
tion of  either  symptom  might  be  made  difficult  or  impossible  by 
swelling. 

Deetz,^  under  the  title  "  subastragaloid  dislocation  with  fracture  of 
the  astragalus  "  reported  a  case  and  collected  3  others,  and  Thienhaus  ^ 
reported  a  fifth.  In  Deetz's  case  and  in  one  of  the  three  he  collected 
(Giinzerich)  the  fracture  was  through  the  neck  of  the  bone,  and  the 
anterior  fragment,  together  with  the  rest  of  the  foot,  was  displaced  for- 
ward, so  that  there  was  a  dislocation  of  the  posterior  facet  from  the 
calcaneum.  But  in  his  remaining  two  (Sick  ^  and  Mailland  *)  the  frac- 
ture of  the  astragalus  was  horizontal,  and  the  lower  fragment  was  dis- 
placed forward  from  the  upper  but  retained  its  relation  with  the  rest  of 
the  foot,  so  that  the  injury  was  a  fracture  of  the  astragalns,  not  a  sub- 
astragaloid dislocation.  Thienhaus  does  not  describe  his  fracture,  but 
the  skiagram  suggests  that  most  if  not  all  of  the  lower  surface  went 
forward  with  the  calcaneum ;  the  external  malleolus  also  was  broken. 
Sick,  Mailland,  and  Deetz  reduced,  the  latter  by  open  operation ; 
Giinzerich  and  Thienhaus  removed  the  astragalus ;  their  cases  were 
old. 

Diagnosis  of  Subastragaloid  Dislocations. 

If  the  date  of  the  injury  is  so  recent  that  swelling  has  not  yet  super- 
vened, or  so  remote  that  it  has  disappeared,  the  diaguosis  may  usually 
be  made  with  considerable  ease  and  certainty,  but  if  swelling  is  pres- 
ent it  mav  be  very  difficult.  The  important  functional  features  are 
the  preservation  of  the  normal  movements  in  the  tibio-tarsal  joint, 
and  the  loss  or  the  exaggeration  in  one  or  the  other  direction  of  the 

1  Deetz:  Deutsche  Zeitschrift  fiir  Chir.,  vol.  Ixxiv.  p.  581. 

2  Thieuhuus  :  Annals  of  Surg.,  Feb.,  190(i,  p.  -iOo. 
'  Sick :  Berl.  klin.  Wochenschrift,  1892,  p.  581. 

•^  Mailland:  Gaz.  des  Hopitaux,  1900,  p.  1539. 


918  DISLOCATIONS. 

lateral  and  rotatory  movements  of  the  foot  which  take  place  in  the 
subastragaloid  and  medio-tarsal  joints.  As  no  lateral  motion  takes 
place  in  the  tibio-tarsal  joint,  except  in  the  position  of  full  plantar 
flexion,  the  exaggeration  of  the  normal  movement  to  either  side  must 
be  due,  when  the  ankle  is  sound,  to  injury  of  the  two  last-named  joints. 
The  physical  signs  are  the  preservation  of  the  relations  between  the 
astragalus  and  the  bones  of  the  leg,  as  shown  by  the  normal  relations 
of  the  malleoli  to  the  head  of  the  astragalus  and  by  the  absence  of 
abnormal  projection  of  the  body  of  the  astragalus  in  front  or  behind 
the  tibia,  the  changes  in  length  of  the  front  part  of  the  foot  and  heel, 
and  the  change  in  the  relations  of  the  calcaneum  and  scaphoid  with 
the  astragalus  and  malleoli. 

Treatment  of  Subastragaloid  Dislocations. 

The  statistics  collected  by  Broca  and  Poinsot  give  23  simple  cases 
in  wdiich  reduction  was  attempted ;  to  these  may  be  added  Pick's  ^  case. 
Of  these  24  reduction  was  successfully  made  in  14  and  the  ultimate 
result  was  good  ;  in  2  the  reduction  was  incomplete,  and  1  of  these 
died  of  septicsemia.  The  8  faikires  (excluding  the  2  incomplete  reduc- 
tions) gave  4  secondary  am])utations  with  3  deaths,  3  secondary  re- 
movals of  the  astragalus  with  1  death,  and  1  good  functional  result 
notwithstanding  the  persistence  of  the  deformity. 

In  7  additional  cases  in  which  reduction  was  not  attempted,  4  of 
the  patients  (Du  Bourg,  Dubreuil,  See,  quoted  by  Poinsot,  and  Quenu) 
had  apparently  good  use  of  the  limb,  although  in  1  of  them  sloughing 
and  a  violent  arthritis  followed  the  accident;  in  1,  Brown,"  reduction 
was  made  after  six  months;  in  2  (Sinnigen,  quoted  by  Poinsot,  RafFa') 
the  disability  was  such  that  the  patient  sought  relief ;  Sinnigen  removed 
the  astragalus  and  external  malleolus,  and  at  the  time  of  the  report 
death  by  septicaemia  was  expected ;  Raffa  chiselled  away  the  head  and 
the  neck  of  the  astragalus  and  was  then  able  to  straighten  the  foot ; 
recovery  without  suppuration  ;  good  result. 

In  2  cases  (Verneuil,''  Ore,  quoted  by  Poinsot)  primary  excision  of 
the  astragalus  was  done,  in  each  with  a  good  result.  In  Verneuil's 
there  was  fracture  of  the  astragalus  and  rupture  of  the  peroneal  artery ; 
in  Ore's  an  attempt  to  reduce  had  failed  and  gangrene  of  the  tense 
skin  was  imminent. 

Of  compound  dislocations  17  cases  were  collected  by  Broca  and  6 
additional  by  Poinsot  in  1884,  and  to  these  1  reported  by  Jackson^  and 
mine  are  to  be  added  ;  of  these  reduction  was  made  in  11,  with  2  deaths, 
with  persistent  suppuration  apparently  niaintained  by  necrosis  in  2,  and 
with  secondary  removal  of  the  astragalus  in  1.  In  14  reduction  was 
not  made  ;  in  3  of  these  primary  amputation  Avas  done,  in  10  removal 
of  the  astragalus,  with  2  deaths,  and  in  1  the  head  of  the  astragalus 

1  Pick  :  Lancet,  1880,  vol.  i.  p.  170. 

2  Brown  :  Lancet,  1876,  vol.  i.  p.  314. 

3  Eaflfa  :  Centralblatt  fiir  Chir.,  1885,  p.  211. 

*  Vcrneuil :  Bull,  de  la  Soc.  Anatomiquc,  1872,  p.  493. 

*  Jackson  :  Lancet,  1881,  ii.  p.  590. 


DISLOCATIONS  AT  OR  NEAR   THE  ANKLE.  919 

became  necrosed  and  was  spontaneously  cast  out,  the  patient  recover- 
ing. The  results  of  primary  removal  of  the  astragalus  according  to 
these  statistics  are  rather  better  than  those  of  reduction,  but,  as  has 
been  said  before,  the  value  of  these  statistics  as  a  basis  for  the  choice 
of  a  method  of  treatment  has  been  greatly  diminished  by  the  improve- 
ment in  the  methods  of  treatment  of  open  wounds  that  has  taken  place 
in  the  last  few  years,  and  there  is  good  reason  to  hojie  that  suppuration 
and  its  attendant  dangers  will  be  less  frequent  in  future. 

Reduction,  which  has  sometimes  been  made  by  traction  with  the 
hands  alone,  more  frequently  has  needed  the  aid  of  pulleys,  even  when 
anaesthesia  has  been  employed.  The  knee  should  be  flexed  to  relax 
the  muscles  of  the  calf,  and  the  traction  in  the  lateral  cases  should  be 
downward  and  usually  also  forward,  and  coaptative  pressure  should  be 
made  upon  the  foot  and  leg.  The  cause  of  the  irreducibility  in  some 
cases  is  not  entirely  clear  ;  it  has  been  attributed  to  the  engagement  of 
the  posterior  lip  of  the  astragalus  in  the  groove  on  the  upper  surface 
of  the  calcaneum.  In  one  case  of  oblique  outward  dislocation  I  was 
obliged  to  make  a  longitudinal  incision  along  the  head  of  the  astragalus 
and  disengage  from  beneath  it  the  tendon  of  the  tibialis  anticus. 


TOTAL  DISLOCATION  OF  THE  ASTRAGALUS. 

("Double  Dislocation    of  the  Astragalus") 

This  dislocation  is  a  combination  of  the  two  preceding  ones,  the 
tibio-tarsal  and  the  subastragaloid,  the  astragalus  being  simultaneously 
displaced  from  its  normal  relations  with  the  bones  of  the  leg,  the  cal- 
caneum, and  the  scaphoid.  It  is  much  more  frequent  than  either  of 
the  other  two  and  is  often  compound.  The  astragalus  may  be  displaced 
forward,  backward,  or  to  either  side,  or  to  any  intermediate  position, 
and  may  at  the  same  time  be  rotated  about  any  of  its  axes,  or  it  may 
be  rotated  while  remaining  in  the  tibio-fibular  mortise.  The  varieties 
of  dislocation  are,  consequently,  very  numerous,  but  they  may  be 
grouped  as  dislocations  forward,  backward,  outward  and  fonvard,  and 
inward  and  forward,  these  terms  indicating  the  direction  in  which  the 
astragalus  is  displaced,  and  dislocations  by  rotation,  including  in  the 
latter  only  those  in  which  the  bone  remains  more  or  less  completely 
within  the  mortise. 

The  causes  are  varied,  the  most  common  being  falls  from  a  height 
upon  the  feet  and  violent  twisting  of  the  foot,  as  when  it  has  been 
caught  between  the  spokes  of  a  wheel.  It  is  seldom  })ossible  to  deter- 
mine the  exact  mode  of  production  in  any  given  case,  and  experiment 
upon  the  cadaver  has  not  done  much  to  elucidate  the  subject ;  but  it 
seems  probable  that  dorsal  or  plantar  flexion  and  abduction  or  adduc- 
tion are  requisite  to  rupture  the  ligaments  that  bind  the  astragalus  to 
the  other  bones,  and  that  then  it  is  forced  from  its  ]>lace  by  pressure 
exerted  through  the  bones  of  the  leg. 


920  DISLOCATIONS. 

1.  Dislocation  Forward. 

In  this  form,  which  is  very  rare,  the  astragahis  is  displaced  directly- 
forward.  To  the  briefly  described  and  somewhat  doubtful  cases  col- 
lected by  Malgaigne,  Delorme  ^  added  only  two,  in  one  of  which  (Morel- 
Lavallee)  the  astragalus  had  been  rotated  180  degrees  about  its  vertical 
axis  and  both  malleoli  were  broken  ;  the  foot  was  very  movable  on  the 
astragalus,  and  the  astragalus  on  the  tibia.  The  sides  of  the  bone 
could  be  distinctly  felt,  and  its  posterior  surface,  which  looked  directly 
forward.  Reduction  was  easily  made.  In  the  other  case,  Barrall,  the 
dislocation  was  compound,  the  head  of  the  astragalus  projecting 
through  the  wound  and  resting  on  the  dorsal  surface  of  the  scaphoid. 
Both  it  and  the  foot  were  freely  movable.  The  extensor  tendons  and 
that  of  the  tibialis  anticus  were  ruptured,  the  malleoli  and  calcaneum 
were  broken. 

2.  Dislocation  Outward  and  Forward. 

In  this,  the  most  common  form,  the  head  of  the  astragalus  rests  on 
the  outer  cuneiform  and  the  cuboid  or  even  on  the  fifth  metatarsal,  its 
posterior  part  1}' ing  just  within  the  mortise,  and  is  freely  movable ;  the 
foot  is  adducted  and  inverted  and  usually  displaced  bodily  inward,  so 
that  the  external  malleolus  is  prominent  and  the  internal  hidden,  and 
sometimes  the  adduction  of  the  front  of  the  foot  is  very  marked  and 
combined  with  abduction  of  the  heel.  If  the  dislocation  is  compound 
the  astragalus  presents  in  the  wound,  which  commonly  extends  back- 
ward to  or  beyond  the  external  malleolus.  The  lower  end  of  the 
fibula  may  be  torn  away  from  the  tibia,  and  either  or  both  malleoli 
broken.  With  the  displacement  may  be  combined  various  kinds  and 
degrees  of  rotation  of  the  astragalus,  and  sometimes  the  astragalus 
is  broken. 

3.  Dislocation  Inward  and  Forward. 

In  this,  the  second  in  order  of  frequency,  the  foot  is  everted  and 
abducted,  but  sometimes  is  bodily  displaced  to  the  outer  side  without 
deviation.  The  astragalus  projects  in  front  of  or  below  the  internal 
malleolus,  and  its  head  appears  always  to  be  depressed,  sometimes  so 
far  that  the  bone  must  have  undergone  rotation  of  90  degrees  about  its 
transverse  axis.  In  a  case  reported  by  Hunt^  it  was  so  far  rotated 
about  its  vertical  axis  that  the  head  was  directed  toward  the  middle  of 
the  other  foot.  If  the  injury  is  compound  the  wound  lies  on  the  inner 
side  and  extends  backward  below  the  malleolus.  It  may  be  accom- 
panied by  fracture  of  the  malleolus. 

1  Delorme:  Diet,  de  Med.  et  Chir.  pratiques,  1879,  vol.  xxvii.  p.  640. 

2  Hunt :  Philadelphia  Medical  Times,  1872,  vol.  iii.  p.  50. 


DISLOCATIONS  AT  OB  NEAR   THE  ANKLE.  921 

4.  Dislocation  Inward. 

A  unique  case  is  reported  by  Seiler.^  The  astragalus  lay  directly 
beneath  the  internal  malleohis  and  had  been  so  rotated  that  its  lower 
surface  looked  inward.  A  free  incision  was  made  and  the  bone 
restored  to  its  place.  The  internal  malleolus  and  sustentaculum  tali 
had  been  broken.     Recovery  with  good  function. 

5.  Dislocation  Backward. 

In  this  form,  which  also  is  rare,  the  astragalus  may  be  displaced 
backward  or  backward  and  to  either  side,  and  in  some  of  the  reported 
cases  the  bone  has  been  broken  at  the  neck  and  only  the  posterior  frag- 
ment has  been  displaced.  Malgaigne'  collected  8  cases,  including  one 
reported  by  Denonvilliers,  which  he  places^  among  "  dislocations  by 
rotation  in  place,"  but  which,  I  think,  belongs  here ;  the  cases  are 
Phillips  2,  Lizars,  Liston,  Turner,  Nelaton,  DenonvUliers,  and  one 
anonymously  reported  in  the  Lancet,  1838-39,  vol.  ii.  p.  559.  To 
these  Delorme  adds  5 — Blatin,  Lejeune,  MaeCormac,  Pichorel,  and 
Cheever ;  he  also  quotes  Foucher  as  having  reported  two  cases,  but,  I 
think,  erroneously,  one  of  them  being  Denonvilliers's  case,  the  other 
Thierry's,  a  dislocation  by  rotation.  Another  case  was  reported  by 
Mnnro,^  and  one  by  myself.^  I  saw  a  second  in  May,  1907,  and  another, 
Legros  Clark,  is  reported  in  MacCormac's  paper,  making  17  in  all.  In 
the  eight  printed  in  italics  the  bone  was  broken  at  the  neck,  and  only 
the  posterior  fragment  was  dislocated." 

Of  the  9  not  complicated  by  fracture  of  the  astragalus,  the  disloca- 
tion was  backward  in  6,  backward  and  outward  in  1,  Turner,  and  back- 
ward and  inward  in  2,  Lancet,  Munro.  Reduction  was  made  in  3 
(Lancet,  Blatin,  Munro),  and  failed  in  4,  the  functional  result  being 
good  in  3  of  the  latter ;  Turner,  and  apparently  Nelaton,  removed  the 
astragalus. 

Of  the  8  complicated  by  fracture,  the  displacement  in  Lejeune's  is 
described  as  backward,  in  the  others  as  backward  and  inward;  the 
difference  is  slight,  for  in  the  latter  the  most  prominent  part  of  the 
astragalus  projects  but  little  beyond  the  level  of  the  side  of  the  internal 
malleolus.  The  tendons  of  the  flexor  longus  digitorum  and  tibialis 
posticus  are  displaced  upon  the  inner  side  of  the  malleolus,  and  that 
of  the  flexor  longus  pollicis  sometimes  lies  to  the  outer  side  of  the 
astragalus  and  sometimes  is  pushed  directly  backward  b}^  it.  The 
fragment  is  also  rotated,  so  that  its  trochlear  surface  looks  inward, 
and  its  fractured  surface  is  directed  forward  and  downward.  The  line 
of  fracture  runs  from  the  anterior  border  of  the  trochlea  into  the  groove 

1  Seiler  :  Correspblt.  fiir  Schweiz.  Aertze,  August  15,  1893. 

2  Malgaigne  :  Loc.  cit.,  p.  1058.  ^  Malgaigne :  Loc.  cit.,  p.  1060. 
*  Munro:  Lancet,  1859,  vol.  ii.  p.  364. 

5  Stimson  :  New  York  Medical  Journal,  May  28,  1887,  p.  594. 

6  The  following  are  two  of  the  references :  MaeCormac  (and  Clark's  case),  Transactions 
of  the  Pathological  Society  of  London,  1875,  vol.  xxvi.  p.  174,  with  plate  of  specimen  ob- 
tained two  years  later;  Cheever,  Bo-stor.  Medical  and  Surgical  .Tournal,  1S75,  vol.  x<Mii. 
p.  237. 


922  1)ISL  0  OA  TIOKS. 

occupied  by  the  interosseous  ligament.  In  3,  Lejeune,  MacCormac, 
Denonvilliers,  the  injury  was  compound;  in  Cheever's  the  skin  over 
the  astragahis  sh^ughed,  but  the  ulcer  soon  healed  without  having 
exposed  the  bone. 

Reduction  was  made  in  none,  although  Pichorel  divided  the  tendo 
Achillis,  and  Cheever  successively  divided  the  tendo  Achillis,  the  tibi- 
alis anticus  and  posticus,  the  flexor  longus  digitorum,  and  the  flexor 
longus  pollicis  at  the  toe.  In  three,  MacCormac,  Clark,  Cheever,  the 
patients  recovered  with  good  use  of  the  limb  ;  in  1 ,  Pichorel,  suppura- 
tion followed  and  the  limb  was  amputated;  in  2,  Denonvilliers,  Stira- 
son,  the  posterior  fragment  was  removed  and  both  patients  died,  mine 
of  pneumonia  on  the  ninth  day.    The  result  in  Lejeune's  is  not  stated. 

The  astragalus  can  be  felt  behind  the  ankle,  either  pressing  the  tendo 
Achillis  backward  or  lying  on  one  side  of  it.  If  the  entire  bone  is 
displaced  the  absence  of  the  head  from  its  normal  position  is  shown 
by  the  depressibility  of  the  soft  parts  behind  the  scaphoid.  Marked, 
incorrigible  flexion  of  the  terminal  phalanx  of  the  great  toe  is  noted 
in  three  of  the  cases.  In  mine  the  tendons  of  the  peroneus  longus  and 
brevis  were  displaced  upon  the  outer  side  of  the  external  malleolus. 

In  the  three  cases  in  which  reduction  was  made  the  means  employed 
were  traction  followed  by  extension  of  the  foot,  traction,  direct  pressure, 
and  inversion  of  the  foot,  and  traction  and  direct  pressure  ;  in  Munro's 
case  several  months  elapsed  before  the  patient  regained  good  use  of 
the  limb. 

6.  Dislocation  by  Rotation. 

In  this  class  are  not  included  those  numerous  cases  in  which  the  bone 
has  undergone  rotation  in  connection  with  displacement  from  the  tibia 
and  fibula,  but  only  those  in  which  it  still  lies  mainly  within  the 
mortise. 

Two  distinct  varieties  of  this  class  may  be  made  ;  those  in  which  the 
bone  has  been  rotated  upon  its  vertical  or  transverse  axis,  and  also, 
perhaps,  upon  the  antero-posterior  axis,  but  still  remains  in  great  part 
within  the  mortise  ;  and  those  in  which  the  bone  still  lies  almost  exactly 
in  its  normal  position  between  the  malleoli  and  has  undergone  only 
rotation  about  its  antero-posterior  axis. 

The  division  between  the  first  variety  and  that  of  dislocations  for- 
ward and  inward  is  rather  arbitrary  and  is  perhaps  not  always  to  be 
made  clinically,  and  the  three  cases  collected  by  Malgaigne  difler 
notably  from  one  another.  Barwell,^  in  a  valuable  paper  containing 
a  well-observed  and  well-reported  case  of  his  own  and  abstracts  of  all 
the  other  alleged  cases  except  Chevallez's,  pro])oses  to  term  the  injury 
dislocation  of  the  foot  with  version,  or  with  torsion,  of  the  astragalus, 
applying  the  term  version  to  the  cases  of  rotation  about  the  vertical 
axis,  and  torsion  to  those  of  rotation  about  the  antero-posterior  axis. 
I  see  no  sufficient  reason  for  using  the  term  dislocation  of  the  foot, 
which  has  already  been  employed  for  another  form  of  injury;  and 
version  and  torsion  do  not  in  themselves  indicate  the  sense  in  which 
they  are  used,  but  must  be  accompanied  by  a  definition. 

1  Barwell  :  Medico-C'liirurgical  Trausactious,  1S83,  vol.  Ixvi.  p.  39. 


DISLOCATIONS  AT  OR  NEAR   THE  ANKLE.  923 

Malgaigne  gives  four  cases  of  rotation  about  tlie  vertical  axis,  but 
I  have  placed  one  of  them,  Denonvilliers,  among  the  dislocations 
backward.  To  the  remaining  three  Barwell  adds  two  reported  by 
Yerebely;^  in  three  of  them  the  head  of  the  astragalus  lay  below  the 
internal  malleolus,  in  one  just  behind  it,  and  in  one  just  in  front  of 
the  external  malleolus.  As  they  cannot  well  be  grouped  I  give  a  sum- 
mary of  each. 

Laumonier  :  The  head  of  the  astragalus  protruded  under  the  internal 
malleolus  between  the  tendons  of  the  tibialis  posticus  and  flexor  longus 
digitorum,  the  trochlea  lying  transversely  in  the  mortise  and  forcing 
apart  the  tibia  and  fibula. 

Foucher:^  The  specimen  was  taken  from  a  subject  found  in  the 
dissecting-room.  The  astragalus  had  been  rotated  90  degrees  about  its 
vertical  axis,  the  trochlea  being  still  upright  in  the  mortise,  and  the 
head  below  the  internal  malleolus.  The  tendon  of  the  tibialis  posticus 
and  the  posterior  tibial  artery  lay  in  front  of  the  internal  malleolus. 
The  posterior  half  of  the  astragalus  lay  on  the  calcaneum,  the  latter 
bone  lying  under  the  external  malleolus  and  displaced  forward  and 
outward,  and  its  axis  directed  forward  and  inward.  The  cuboid  was 
partly  dislocated  downward  from  the  calcaneum.  There  was  no  cica- 
trix ;  the  foot  was  flattened,  the  heel  shortened. 

Thierry  :  The  head  of  the  astragalus  projected  midway  between  the 
internal  malleolus  and  the  tendo  Achillis,  the  outer  border  of  the  foot 
was  much  raised,  and  it  was  then  seen  that  the  bone  was  also  so  turned 
that  its  upper  surface  looked  forward  and  inward,  the  tibia  resting  on 
the  internal  lateral  face  of  the  body  of  the  bone,  and  the  internal  border 
of  the  trochlea  exactly  occupied  the  angle  between  the  internal  mal- 
leolus and  the  under  surface  of  the  tibia.     Amputation  ;  recovery. 

Verebely  :  Male,  twenty-nine.  Fibula  fractured  above  the  malle- 
olus. Under  the  internal  malleolus  the  skin  was  very  tense ;  about 
an  inch  lower  there  was  a  hard  bony  prominence  about  half  an  inch 
in  diameter.  Reduction  failed.  At  the  end  of  the  third  week  an 
abscess  was  opened,  and  it  was  seen  that  the  prominence  under  the 
malleolus  was  the  head  of  the  astragalus.  After  four  months'  treat- 
ment the  man  could  with  difficulty  put  the  foot  to  the  ground. 

Verebely,  second  case  :  Male,  forty-five.  The  foot  was  at  right 
angles  with  the  leg,  the  sole  looking  somewhat  inward  and  upN\'ard. 
"  Under  the  easily  distinguishable  outer  malleolus  and  in  front  of  it  a 
long  projection  half  an  inch  in  diameter  may  be  plainly  felt;  this  can 
be  moved  without  much  pain  backward  and  forward  independently  of 
the  other  bones.  Behind  the  scaphoid  is  a  considerable  hollow." 
Reduction  failed. 

Of  the  second  variety,  rotation  about  the  antero-posterior  axis,  ]\Ial- 
gaigne  gives  seven  cases,  most  of  whirh  Barwell  rejects  because  of  the 
incompleteness  of  the  description  or  because  the  astragalus  was  more 
or  less  displaced  from  the  mortise.  Rejecting  Boyer's,  Smith's,  Lis- 
ten's, and  two  of  Dupuytren's,  there  still  remain  Malgaigne's  own  and 

1  Verebely  :  Wiener  med.  Wocliensehrift,  1869.  vol.  xix.  pp.  27fl  iiiid  ■2'M. 
'  Foucher :  Bull,  de  la  Societe  Anatomique,  1854,  vol.  xxix.  p.  3SS. 


924  DISLOCATIONS. 

one  of  Dupuytren's ;  to  these  are  to  be  added  BarwelTs  and  Gheval- 
lez's.^  In  all  four  cases  the  condition  was  shown  by  direct  examina- 
tion :  Malgaigne  describes  a  specimen  from  an  old  case,  Chevallez's 
patient  was  killed  by  the  fall  that  caused  the  dislocation,  and  Dupuy- 
tren  and  Barwell  excised  the  astragalus.  In  Malgaigne's,  Chevallez's, 
and  Barwell's  the  rotation  was  outward,  that  is,  the  upper  surface  of 
the  trochlea  had  become  external  and  rested  against  the  inner  face  of 
the  external  malleolus,  although  in  Malgaigne's  the  rotation  was  some- 
what less  than  90  degrees ;  in  Dupuytren's  the  bone  was  turned  com- 
pletely upside  down,  rotation  of  1 80  degrees. 

Of  Malgaigne's  specimen,  which  is  represented  in  his  Atlas,  Plate 
XXX.,  Fig.  5,  it  is  said  that  the  head  of  the  astragalus  rested  on  the 
scaphoid  and  cuboid  ;  its  trochlea,  turned  outward,  corresponded  almost 
entirely  to  the  inner  facet  of  the  fibula,  and  its  inner  side  lay  under 
the  tibia.  The  rotation,  however,  was  not  a  complete  quarter  of  a 
circle,  for  a  portion  of  tlie  outer  side  of  the  body  of  the  astragalus 
could  still  be  seen  partly  in  contact  with  the  point  of  the  external 
malleolus  and  looking  downward  and  outward.  There  was  bony 
anchylosis  between  the  astragalus  and  calcaneum,  and  it  was  evident 
that  the  man  had  walked  only  on  the  outer  border  of  his  foot. 

In  Chevallez's  specimen  there  was  subluxation  of  the  head  of  the 
astragalus  on  the  scaphoid,  the  upper  surface  of  the  trochlea  was 
turned  outward,  the  calcaneum  was  broken  transversely  and  its  pos- 
terior fragment  driven  up  behind  the  astragalus ;  the  lateral  ligaments 
of  the  ankle  were  detached,  and  the  anterior  border  of  the  lower  end 
of  the  tibia  was  broken. 

Dupuytren's  patient  was  a  man  fifty  years  old,  who  had  jumped 
from  a  ladder,  alighting  on  his  heel.  There  was  a  large,  hard,  irreg- 
ular, and  irreducible  prominence  in  front  of  the  tibia  and  extending 
to  the  instep.  An  incision  was  made  parallel  to  the  axis  of  the  foot, 
and  the  head  and  neck  of  the  astragalus  were  immediately  brought 
into  view.  Efforts  to  remove  the  bone  failed,  for  the  posterior  part 
was  grasped  and  held  fast  between  the  tibia  and  calcaneum.  On  seek- 
ing for  tiie  cause  of  this  fixation  it  was  found  that  the  astragalus  was 
turned  around  in  such  a  way  that  its  upper  surface  was  directed  down- 
ward, its  lower  upward,  and  that  the  hook-like  process  at  its  inferior 
and  posterior  part  was  fixed  beneath  the  tibia  so  as  completely  to 
frustrate  our  efforts  to  extract  it.     The  patient  did  well. 

Barwell's  patient,  a  man  twenty-eight  years  old,  was  injured  by  the 
overturning  of  his  wagon.  When  seen  an  hour  and  a  half  after  the 
accident  the  foot  was  greatly  inverted,  its  front  somewhat  turned  in, 
the  heel  raised.  The  inner  malleolus  was  much  hidden  ;  beneath  it  the 
skin  was  thrown  into  two  ridges  by  three  deep  folds  drawn  in  segments 
of  concentric  circles  from  a  centre  a  little  above  the  malleolus.  The 
outer  malleolus  projected  abnormally,  the  skin  over  it  was  rather 
tightly  drawn.  About  an  inch  in  front  of  it  and  a  little  below  its 
level  was  a  rounded  projection,  which  also  somewhat  stretched  the  skin. 
An  inch  and  a  half  up  the  leg  and  in  front  of  the  fibula  was  a  small 
1  Chevallez:  Bull,  de  la  Soc.  Anatomique,  1870,  vol.  xlv.p.  406. 


DISLOCATIONS  AT  OR  NEAR   THE  ANKLE.  025 

but  deep  wound.  Below  and  in  front  of  the  inner  malleolus  deep 
pressure  revealed  absence  of  the  usual  bony  substratum,  the  finger 
sank  into  a  hollow  bounded  in  front  by  the  tuberosity  of  the  scaphoid, 
which  lay  abnormally  near  the  malleolus.  The  rounded  projection  in 
front  of  the  external  malleolus  could  readily  be  recognized  as  the  head 
of  the  astragalus.  A  little  way  behind  tliis  was  a  ridge  of  bone,  also 
evidently  a  part  of  the  astragalus ;  it  led  from  the  head  backward  and 
a  little  upward,  disappearing  under  the  upper  part  of  the  malleolus,  at 
the  angle  between  it  and  the  anterior  edge  of  the  tibia.  This  ridge  was 
markedly  convex  outioard.  The  extensor  tendons,  pressed  together, 
ran  in  a  bundle  a  little  distance  inside  the  rounded  projection.  The 
wound  communicated  with  the  injury.     No  fracture  could  be  detected. 

It  was  seen  that  the  relations  of  the  astragalus  to  the  other  bones 
were  altered,  although  it  ^Yas  still  within  the  mortise,  but  the  exact 
nature  of  the  injury  was  not  recognized.  Various  attempts  were  made 
to  reduce,  and  even  the  tendo  Achillis  was  divided,  but  in  vain  ;  a 
moulded  splint  was  applied,  and  the  wound  dressed  with  carbolic  acid. 

Two  days  later  a  semilunar  incision  was  made  from  the  middle  of 
the  lower  end  of  the  tibia  across  the  head  of  the  astragalus  to  the  tip 
of  the  outer  malleolus,  the  flap  turned  up,  and  the  bone  fully  exposed. 
It  was  a  little  turned  on  its  vertical  axis,  the  head  having  mover)  out- 
ward, and  90  degrees  on  its  antero-posterior  axis,  the  trochlea  being  in 
contact  with  the  cartilaginous  surface  of  the  external  malleolus.  The 
inner  upper  angle  of  the  trochlea  fitted  closely  into  the  reentrant  angle 
formed  by  the  external  malleolus  and  the  tibia.  The  bone  was  not  at 
all  displaced  forward — that  is,  it  did  not  protrude  abnormally  from  its 
socket.  The  interosseous  ligament  had  been  ruptured  ;  the  few  remain- 
ing fibres  were  divided,  and  the  bone  removed.  Examination  of  the 
cavity  failed  to  show  any  fracture  or  detachment  of  cartilage.  The 
patient  made  a  good  recovery,  and  was  discharged  nine  and  a  half 
weeks  after  the  operation. 

Treatment  of  Total  Dislocations  of  the  Astragalus. 

The  statistics,  (jollected  by  Broca,  Dubreuil,  and  Poinsot,  show  that 
of  121  cases  of  dislocations  not  compound,  43  were  successfully 
reduced,  and  it  is  worthy  of  note  that  Poinsot's  list,  composed  of 
cases  reported  between  1864  and  1883,  shows  19  reductions  in  31 
cases,  about  60  per  cent.,  and  as  many  of  Broca's  cases  were  treated 
without  the  aid  of  anaesthesia  it  may  reasonably  be  hoped  that  Poin- 
sot's percentage  is  an  indication  of  the  success  that  will  be  obtained  in 
the  future.  Primary  extirpation  of  the  astragalus  was  done  in  9  of  the 
121  cases,  with  6  successes,  1  death,  and  2  deaths  after  secondary  am- 
putation. Consecutive  extirpation  was  done  in  41  cases,  with  39  suc- 
cesses and  2  deaths.  Of  15  cases  in  which  the  dislocation  remained 
unreduced  and  in  which  the  result  is  known  (excluding  those  of  sec- 
ondary extirpation)  the  functional  result  in  8  was  good. 

Of  63  compound  dislocations,  collected  by  Broca,  reduction  was 
made  in  9,  and  of  these  9  cases  6  recovered,  secondary  removal  of  the 


926  DISLOCATIONS. 

astragalus  was  done  in  2,  and  1  died.  Poinsot  adds  2  cases  in  which 
reduction  was  made ;  1  was  successful,  in  the  other  extirpation  became 
necessary. 

In  58  compound  cases  primary  removal  of  the  astragalus  was  done, 
with  4.2  successes,  14  deaths,  and  2  consecutive  amputations  followed 
by  death. 

For  reasons  that  have  been  already  given,  we  have  the  right  to 
expect  better  results  in  the  future  in  compound  cases,  and  may  feel 
encouraged  to  make  reduction  whenever  it  is  possible.  Expectation 
in  irreducible  compound  dislocations  has  almost  always  ended  in 
removal  of  the  astragalus,  or  amputation,  or  death,  and  the  cases  will 
probably  be  very  few  in  which  primary  removal  of  the  astragalus  will 
not  give  the  patient  the  most  speedy  recovery,  the  least  risk,  and  the 
most  useful  limlj. 

Of  56  simple  irreducible  dislocations  contained  in  these  statistics, 
suppuration  of  the  joint  and  sloughing  of  the  skin  followed  in  at  least 
41,  and  there  is  not  much  reason  to  suppose  that  the  frequency  of  this 
result  will  be  much,  if  at  all,  diminished  in  the  future,  for  the  excit- 
ing cause — bruising,  pressure,  and  destruction  of  the  blood-supply  of 
the  astragalus — will  be  repeated.  It  is  important,  therefore,  to  deter- 
mine the  proper  course  to  be  pursued  under  such  circumstances.  In 
1884  Dr.  McBurney,  of  Xew  York,  successfully  reduced  a  dislocation 
forward  and  inward  by  exposing  the  head  of  the  astragalus  through 
an  incision,  and  lifting  the  tendon  of  the  tibialis  anticus  which  tightly 
embraced  the  neck  of  the  bone  and  had  prevented  reduction  ;  other 
equally  good  results  have  since  been  obtained  by  the  same  means. 
Primary  removal  of  the  astragalus  is  recommended  by  Barwell  in  all 
cases  in  w^hich  "certain  and  sufficient  but  not  too  persevering,  attempts 
at  reduction  "  have  failed,  and  the  facts  that  four-fifths  of  the  cases 
left  to  themselves  have  ended  in  suppuration  and  secondary  removal 
of  the  astragalus,  and  that  the  functional  result  after  removal  is  good, 
will  be  generally  accepted  as  a  justification  of  the  advice,  but  it  needs, 
I  think,  to  be  conditioned  upon  the  failure  of  reduction  by  arthrotomy. 

In  short,  the  plan  to  be  pursued  in  simple  cases  is  to  attempt  reduc- 
tion by  traction  upon  the  foot  with  the  hands  or  pulleys,  under  anaes- 
thesia, and  with  the  knee  flexed,  and  by  direct  pressure  so  applied  as 
first  to  correct  such  rotation  of  the  bone  as  may  exist,  and  then  to 
force  it  back  into  place.  This  failing,  expose  the  bone  by  incision,  and 
seek  to  remove  the  obstacle  to  reduction  and  then  to  reduce ;  this  also 
failing,  remove  the  astragalus.  In  cases  in  which  the  astragalus  is  not 
only  dislocated  but  also  broken,  I  think  primary  removal  is  the  safest 
plan,  even  in  cases  of  backward  dislocation  of  the  posterior  fragment, 
although  in  three  such  treated  without  removal  the  patients  recovered 
with  useful  limbs. 

In  compound  dislocations  reduction  is  to  be  sought  unless  the 
astragalus  is  entirely  detached  or  the  lacerations  are  so  extensive  that 
suppuration  is  unavoidable  ;  otherwise,  primary  removal  of  the  astrag- 
alus, or  amputation  if  clearly  indicated. 


DISLOCATIOyS  AT  OR  NEAR   THE  ANKLE.  927 

MEDIO-TARSAL  DISLOCATION. 

In  this  the  dislocation  takes  place  in  the  medio-tarsal  joint,  the 
scaphoid  and  cuboid  being  together  displaced  from  the  astragalus  and 
calcaneum  which  preserve  their  relations  to  each  other  and  to  the 
bones  of  the  leg.  Broca,  in  the  paper  above  quoted,  pointed  out  that 
most  dislocations  previously  reported  under  this  title  -vvere  actually 
subastragaloid.  Partial  dislocation  of  the  cuboid  from  the  calcaneum 
appears  to  be  frequently  associated  with  subastragaloid  dislocations, 
but  the  cases  in  which  the  raedio-tarsal  joint  alone  is  involved  are  few. 
Cases  too  briefly  described  to  be  positively  accepted  were  reported  by 
J.  Ij.  Petit,  Liston,  and  Cooper,  but  more  recently  four  cases  have 
been  placed  on  record  in  two  of  which  the  diagnosis  was  confirmed  at 
the  autopsy.  Thomas^  reported  a  case  in  the  service  of  Denonvilliers; 
the  patient's  foot  had  been  crushed  by  the  wheel  of  a  cart.  The  plan- 
tar surface  was  convex,  the  dorsum  so  swollen  that  the  bones  could 
not  be  felt ;  the  foot  was  shortened,  and  its  anterior  portion  could  be 
moved  laterally,  but  the  movements  were  painful  and  accompanied  by 
crepitus.  The  diagnosis  of  fracture  of  the  head  or  neck  of  the  astrag- 
alus and  rupture  of  the  calcaneo-cuboid  ligaments  was  made.  Tlie 
patient  died  of  erysipelas,  and  at  the  autopsy  the  tibio-tarsal  and  cal- 
caneo-astragaloid  joints  were  found  intact;  the  head  of  the  astragalus 
and  the  cuboid  surface  of  the  calcaneum  formed  a  very  marked  abnor- 
mal prominence  above  the  second  row  of  the  tarsus ;  the  scaphoid  was 
fractured  antero-posteriorly,  and  its  outer  fragment  projected  on  the 
plantar  surface ;  the  cuboid  M'as  still  in  contact  Avith  the  inferior  lialf 
of  the  anterior  end  of  the  calcaneum  ;  the  superior  medio-tarsal  liga- 
ments were  ruptured,  and  the  inferior  calcaneo-scaphoid  partly 
detached  ;  the  inferior  calcaneo-cuboid  was  unbroken. 

Anger's"  patient  was  injured  by  a  fall  from  a  height.  There  Avas 
slight  flattening  of  the  arch  of  the  foot,  w^ithout  deviation,  and  with 
considerable  ecchymotic  and  inflammatory  swelling.  He  died  of  ery- 
sipelas. At  the  autopsy  the  head  of  the  astragalus  was  found  above 
and  in  front  of  the  scaphoid,  and  the  cuboid  facet  of  the  calcaneum 
upon  the  upper  surface  of  the  cuboid.  The  superior  calcaneo-scaphoid 
and  internal  calcaneo-cuboid  ligaments  were  ruptured  and  torn  from 
tlieir  anterior  insertions.  It  was  difficult  to  reduce  the  dislocation  even 
after  dissection.  The  only  fracture  was  of  the  anterior  part  of  the 
scaphoid,  the  tubercle  of  which  was  almost  entirely  torn  away. 

In  the  third  case,  Ward,^  the  dislocation  was  old.  "  The  foot  pre- 
sented a  remarkably  twisted  appearance,  the  anterior  part  being  directed 
consideral^ly  inward,  and  the  inner  edge  somewhat  elevated.  The 
dorsum  was  shortened  one  inch.  The  anterior  ends  of  tiie  calcaneum 
and  astragalus  projected  distinctly  on  the  dorsum.  The  external  mal- 
leolus had  been  fractured. 

In  the  fourth,  Fuhr,*  the  dislocation  was  outward.     The  patient  was 

1  Thomas :  Mem.  de  la  Soc.  Med.  d'Indre  et  Loire,  1887,  quoted  by  1  )ii  play  and  I  )L'lorme. 

-  B.  Anger:  Traite  iconographiiiiie,  p.  334. 

•'  Ward  :  Transactions  of  the  Pathological  Society  of  Loudon,  ISllt-.Vi,  p.  2'A. 

•*  Fuhr :  Miinch.  med.  Woch.,  Marcli  8,  1892. 


928  DISLOCATIONS. 

sixty-six  years  old  and  had  fallen  six  feet;  the  foot  was  slightly  pro- 
nated  and  the  projection  of  the  posterior  surfaces  of  the  scaphoid  and 
cuboid  could  be  distinctly  felt  in  front  of  the  external  malleolus. 

The  .r-rays  have  added  notably  to  the  number  of  reported  cases. 
]vluller^  collected  several  and  Skillern-  reported  one  with  the  bibliog- 
raphy and  a  formal  study  of  the  subject. 

As  the  above-mentioned  cases  show  the  dislocation  may  be  complete 
or  incomplete,  and  the  displacement  (of  the  front  of  the  foot)  may  be 
toward  the  dorsum  or  the  sole  or  outward.  Apparently  the  separation 
of  the  scaphoid  from  the  astragalus  is  generally  complete,  that  of  the 
cuboid  from  the  calcaneum  less  frequently  so. 

CONGENITAL  DISLOCATIONS  OF  THE  ANKLE-JOINT. 

Kraske^  exhibited  at  the  Xinth  Congress  of  the  German  Surgical 
Societv  two  patients,  father  and  son,  with  congenital  dislocation  of 
both  ankles,  and  also  the  two  legs  of  another  child  of  the  same  father 
which  had  died  in  infancy  and  had  been  similarily  affected.  The 
abnormality  was  a  subluxation  outward  accompanied  by,  and  probably 
due  to,  defective  development  of  the  fibula.  In  all  three  cases  the 
middle  and  upper  part  of  the  fibula  was  lacking,  but  in  the  specimen 
a  small  upper  epiphysis  existed.  In  the  father  the  lower  end  of  the 
fibula  was  only  four  centimetres  long  and  was  obliquely  placed,  the 
apex  directed  outward.  The  articular  surface  of  the  tibia  was  also 
oblique,  looking  downward  and  outward  ;  the  foot  was  flattened,  mark- 
edlv  abducted,  and  moderately  pronated.  The  legs,  compared  with 
the  thighs,  were  abnormally  short  and  slight. 

Resection  of  both  ankles  had  been  done  upon  the  son  to  correct  the 
faulty  position  of  the  foot:  on  the  right  side  the  internal  malleolus 
and  a  comparatively  large  part  of  the  astragalus  had  been  removed  ; 
on  the  left,  the  entire  lower  end  of  the  tibia  and  a  small  piece  of  th<} 
astragalus. 

Other  forms  of  congenital  subluxation  belong  to  the  subject  of 
clubfoot. 

1  Miiller:  Fortschr.  Gel.  Roentgenstrahlen,   vol.  xviii,  p.   187. 

2  Skillern:  Annals  of   Stirg.,   June,    1913,   p.   917. 

3  Kraske:  Beilage  zum  Centralblatt  flir  Chir.,  1882,  No.  29,  p.  85. 


CHAPTER   LVIIL 

DISLOCATIONS  OF  THE  TARSAL  AND  METATARSAL  BONES 
AND   OF   THE  TOES. 

In  addition  to  the  dislocations  described  in  the  preceding  chapter, 
the  bones  of  the  tarsns  may  be  dislocated  sei)arately  and  in  various 
combinations.  None  of  the  diiferent  kinds  has  occurred  with  suffi- 
cient frequency  to  permit  systematic  grouping  and  description,  and  in 
most  of  them  the  exact  nature  of  the  injury  cannot  be  said  to  have 
been  positively  established,  for  the  difficulties  of  the  diagnosis  upon 
the  living  are  usually  very  great  and  the  surgeon  is  limited  to  the 
recognition  of  the  more  prominent  features.  I  shall  confine  the 
account  of  them  mainly  to  the  enumeration  of  the  different  varieties 
that  have  been  observed,  with  bibliographical  references  for  the  con- 
venience of  those  who  may  desire  to  examine  the  reports  in  detail. 

Calcaneum.  Malgaigne  quotes  a  case  in  M'hich  the  calcaneum  was 
bodily  displaced  to  the  outer  side,  but  apparently  was  not  entirely  sep- 
arated from  the  astragalus  and  scaphoid.  Reduction  was  easy.  Also 
a  second,  Canton,^  found  upon  the  cadaver,  in  which  the  calcaneum 
was  displaced  to  the  outer  side  together  with  the  external  malleolus ; 
its  anterior  end  lay  between  the  cuboid  and  scaphoid,  almost  in  con- 
tact with  the  third  cuneiform  ;  and  the  astragalus  was  rotated  inward 
about  45  degrees. 

Scaphoid.^  The  scaphoid  has  been  totally  displaced  forward  upon 
the  dorsum  in  5  cases,  forward  and  inward  in  1,  inward  in  3,  toward 
the  sole  in  1,  and  outward  on  the  dorsum  in  2.  Four  were  reduced 
without,  and  one  by  operation,  3  were  left  unreduced  with  a  good 
functional  result,  in  1  the  bone  was  removed,  and  in  2  amputation  was 
done  because  of  gangrene. 

The  scaphoid  has  been  dislocated  forward  and  outward  in  connection 
w'ith  the  astragalus,  the  dislocation  being  compound  (Burnett),  forward 
and  inward  (Rizzoli,  quoted  by  Poiusot),  upward  and  backward  in  con- 
junction with  the  first  and  second  cuneiforms  and  the  first  two  meta- 
tarsals and  with  dislocation  of  the  third  metatarsal  and  fracture  of  the 
cuboid  (Chassaignac^),  upAvard  and  inward  in  conjunction  with  the  first 
cuneiform  (Lonsdale*),  or  with  the  middle  cuneiform  (Clarke^),  or  out- 
ward, upward,  or  inward  alone  (Piedagnel,  Walker,  R.  AY.  Smith, 
quoted  by  iMalgaigne,  Bryant  ^j,  or  from  the  cuneiforms  only,  as  seen 
by  Garland  '^  in  a  case  that  Avas  compound.      In  a  case  reported  by 

1  Canton  :  Lancet,  1847,  vol.  i.  p.  505. 

2  See  Capillery  and  Ferron  :  Rev.  de  Chir..  vol.  xxxiv.  p.  93;  Eichel,  Deutsche  Ztschft. 
fiir  Chir.,  vol.  Ixxxvili.  p.  324;  Gottstein,  Ztlblatt.  fur  Chir.,  1909,  p.  1528,  and  C.  E.  Farr, 
personal  communication. 

3  Chassaignac:  Bull,  de  la  Sec.  de  Cliir.,  18G1,  vol.  i.  p.  307. 

*  Lonsdale  :  Lancet,  1857,  vol.  ii.  p.  192. 

6  Clarke :  London  Medical  Times,  1851,  vol.  iii.  p.  2.3.3. 

*  Bryant :  Surgery,  3d  American  edition,  1881,  p.  813. 
'  Garland  :  Lancet,  1857,  vol.  ii.  p.  270. 

(929) 


930  DISL  OCA  TIONS. 

Enos^  tlie  cuneiform  bones  and  the  cuboid  Avere   displaced   outward 
from  the  scaphoid  and  calcaneum. 

Cuboid.  The  only  case  of  dislocation  of  the  cuboid  of  which  I  have 
knowledge,  except  in  connection  with  other  dislocations  as  above 
described,  is  one  reported  by  Bell,^  in  which  it  was  disjalaced  upward 
in  connection  with  the  fifth  metatarsal  by  inversion  and  adduction  of 
the  foot.     Reduction  was  made. 

Cuneiform  Bones.  All  three  cuneiform  bones  and  the  second  and 
third  have  been  displaced  together,  and  the  first  and  second  have  been 
displaced  separately.  Isolated  dislocations  of  the  first  are  the  most 
frequent,  Lemoine  ^  collected  eleven  such  cases,  to  which  may  be  added 
two  observed  by  Bryant;*  the  displacement  is  usually  upward  and 
inward,  in  only  one  case  downward  and  inward  (Fitzgibbon^) ;  some- 
times the  bone  is  displaced  from  all  the  three  with  which  it  is  normally 
in  contact,  sometimes  the  first  metatarsal  is  displaced  with  it.  The 
symptoms  are  flattening  of  the  arch  of  the  foot,  prominence  of  the 
displaced  bone,  and  a  depression  at  its  normal  site.  In  some  cases 
reduction  has  been  easily  made ;  in  others  the  attem})t  has  failed. 

The  second  cuneiform  has  been  separately  dislocated  upon  the 
dorsum  in  seven  cases,  Foulker,^  Laugier,  Lagrade  (quoted  by  Del- 
orme  '^),  and  Haifner,^  4  cases,  the  displacement  being  slight  in  one  and 
nearly  complete  in  the  others,  and  accompanied  in  one  by  other  serious 
injuries  of  the  foot,  and  followed  in  another  (Foulker)  by  sloughing  of 
the  skin,  grave  symptoms,  and  ultimate  recovery.  In  a  case  of  multiple 
injuries  of  the  foot  reported  by  Lagrange  ^  the  second  cuneiform  was 
displaced  upward  from  all  its  connections  except  that  with  the  scap- 
hoid. 

The  second  and  third  cuneiforms  were  displaced  together  upon  the 
dorsum  in  a  case  reported  by  Key  (quoted  by  Malgaigne)  ;  the  dislo- 
cation, which  was  incomplete,  was  caused  by  direct  violence  and  accom- 
panied by  extensive  laceration  of  the  skin.     The  patient  died. 

All  three  cuneiforms  have  been  reported  displaced  together  upon  the 
dorsum  in  several  cases,  but  it  does  not  always  appear  in  the  histories 
whether  or  not  they  were  separated  only  from  the  scaphoid  or  also 
from  the  cuboid  and  metatarsals ;  in  one  of  them,  Bertherand  ^°  they 
Avere  accompanied  by  the  metatarsals  and  the  dislocation  could  not  be 
reduced. 

In  Blecher's  ^^  they  were  totally  separated  ;  the  second  and  third  lay 
on  the  dorsum,  the  first  in  the  sole ;  they  were  removed  by  operation, 
with  a  fair  functional  result. 

1  Enos :  New  York  Journal  of  Medicine,  1857,  vol.  vii.  p.  98. 

2  Bell :  New  York  Journal  of  Medicine,  1859,  vol.  vii.  p.  329. 

3  Lemoine  :  Revue  de  Chirurgie,  1883,  vol.  iii.  p.  118. 
*  Bryant :  Loc.  cit.,  p.  813. 

s  Fitzgibbon :  Dublin  Journal  of  the  Medical  Sciences,  1877,  vol.  ii.  p.  271. 

6  Foulker :  Lancet,  1856,  vol.  ii.  p.  283. 

'  Delorme :  Diet,  de  Med.  et  Chir.  prat.  vol.  xxvii.  art.  Pied. 

**  Haffner:  Beitrage  zur  klin.  Chir.,  vol.  Iii.  p.  573. 

9  Lagrange :  Bull,  de  la  Soc,  Anatomique,  1871,  p.  180. 

10  Bertherand:  Bull,  de  la  Soc.  de  Chir.,  1856-57,  vol.  vii.  p.  361. 

11  Blecher  :  Deutsche  Ztschft  f  iir  Chir.,  vol.  Ivlll.  p.  332. 


DISLOCATIONS  OF  THE  METATARSAL  BONES.  931 

DISLOCATIONS  OF  THE  METATARSAL  BONES  FROM  THE  TARSUS 
AND  FROM  ONE  ANOTHER. 

Malgaigne  collected  twenty-one  cases  of  the  various  dislocations, 
Hitzig/  twenty-nine  ;  Bayer,^  sixty-eight ;  and  Fischer,^  eighteen  of 
the  first  metatarsal. 

The  first  metatarsal  is  much  more  frequently  dislocated  than  the 
others,  and  the  displacement  has  generally  been  upward.  In  one  case, 
Demarquay/  the  base  lay  under  that  of  the  second  metatarsal ;  and  the 
other  end  of  the  bone  was  also  dislocated,  compound  ;  Demarquay 
removed  the  bone.  Fischer  saw  four  such  double  cases.  A  frequent 
cause  has  been  a  fall  while  on  a  horse,  the  pressure  of  the  stirrup  against 
the  inner  and  under  surface  of  the  bone  apparently  causing  the  injury. 
The  symptoms  frequently  indicate  the  coexistence  of  a  sprain  of  neigh- 
boring joints.  Reduction  has  always  been  easy  by  traction  and  direct 
pressure. 

Isolated  dislocation  of  the  second  metatarsal  upon  the  dorsum  has 
been  reported  in  one  case,  Brault  and  Belin,  quoted  by  Hitzig ;  that  of 
the  third  downward  and  backward  in  one,  Tufnell;^  that  of  the  fourth 
upon  the  dorsum  in  three,  Malgaigne,  Surmay,^  and  Gosselin.'^ 

The  fourth  and  fifth  metatarsals  have  been  together  dislocated  upward 
and  inward,  Monteggia,  and  upward  and  backward.  South  ;  both  quoted 
by  Malgaigne.  The  third  and  fourth,  Hartmann,  and  the  first  and 
second,  Marit,  have  been  together  displaced  ;  both  quoted  by  Delorme.^ 
The  first,  second,  and  third  were  dislocated  together  upon  the  dorsum 
in  two  cases,  Laugier,  quoted  by  Malgaigne,  and  Wilms,  quoted  by 
Hitzig,  and  downward  into  the  sole  in  a  case  reported  by  Tnfnell ;  ^  in 
the  latter  case  the  injury  was  caused  by  the  fall  of  a  horse  and  was 
irreducible,  but  the  patient  recovered  good  use  of  the  limb ;  the  later 
history  is  recorded  in  the  same  journal,  1855,  vol.  xx.  p.  302. 

Dislocation  of  the  second,  third,  and  fourth  together  upon  the  dor- 
sum was  seen  by  Malgaigne  once ;  the  same  diagnosis  was  made  by 
him  in  another  case,  but  at  the  autopsy  it  was  found  that  the  fifth  was 
also  partly  dislocated  from  the  cuboid  and  that  the  first  togetlier  with 
the  internal  cuneiform  was  displaced  inward.  A  case  is  reported  by 
Favier.^'' 

Dislocation  of  the  first  four  metatarsals  have  been  reported  in  four 
cases,  Malgaigne,  Hitzig,  Demarquay, ^^Ely  ;  ^^  in  Malgaigne's  the  first 
three  were  displaced  downward,  the  fourth  upward;  in  Ely's  the  first 
inward,  the   others   upward   and  outward  ;  in  tiie  other  two  the  dis- 

1  Hitzig :  Berl.  klin.  Wochenschrift,  1865,  p.  393. 

2  Bayer  :  Sammlung  klin.  Vortrage  N.  F.,  No.  372. 

3  Fischer:  Deutsche  Zeitschrift  fiir  Chir.,  vol.  Ixxiv.  p.  55. 
■'Demarquay:  Bull,  de  la  Soc.  de  Chir.,  1870,  vol.  x.  p.  35. 

5  Tufnell :  Dublin  Quarterly  Journal  of  the  Medical  Sciences,  1835,  p.  302. 

^Surmay:  Bull,  de  la  Soc.  de  Chir.,  1876,  vol.  ii.  p.  579. 

"'  Gosselin :  Gaz.  des  Hopitaux,  1876,  p.  755. 

^Delorme:  Diet,  de  Med.  et  Cliir.,  prat.  vol.  xxvii.  art.  Pied. 

•'  Tufnell :  Dublin  Quarterly  Journal  of  the  Medical  Sciences,  1854,  vol.  xvii.  p.  65. 
'OFa\aer:  Arch,  de  Med.  et  Pharm.  mil.,  November,  1888, 
'1  Demarquay:  Gaz.  des  Hopitaux,  1865,  p.  534. 
12 Ely:  Annals  of  Surg.,  Aug.,  1906. 

G4 


932  DISLOGA  TIONS. 

placement  was  upward.  Malgaigne  was  able  to  reduce  the  fourth, 
Demarquay  the  first,  and  Hitzig  all ;  notwithstanding  the  persistence 
of  part  of  the  dislocation  the  two  patients  had  good  use  of  the  limb. 

AH  the  metatarsal  bones  may  be  displaced  together  upward,  inward, 
downward,  or  outward  ;  of  the  latter  two  forms  only  one  example  of 
each  has  been  reported.  Smyly^  saw  all  five  bones  dislocated  down- 
ward by  the  fall  of  a  wagon  which  pressed  the  heel  forward  while  the 
toes  were  fixed  ;  reduction  was  made.  The  case  of  dislocation  inward 
is  Kirk's,  quoted  by  Malgaigne,  who  distrusts  the  diagnosis. 

Of  dislocation  outward  ten  cases  have  been  reported  :  Laugier  and 
Lacombe,  quoted  by  Malgaigne,  Tutschek,  quoted  by  Hitzig,  Mignot- 
Danton,^  Despres,^  and  five  quoted  by  Bayer.  The  interlocking  of 
the  base  of  the  second  metatarsal  between  the  first  and  third  cuneiform 
bones  must  make  a  lateral  dislocation  impossible  except  as  secondary  to 
one  upward  or  downward  or  unless  accompanied  by  fracture ;  in 
Laugier's  and  Despres's  the  second  metatarsal  was  broken  at  its  upper 
end,  and  in  Mignot-Danton's  and  Lacombe's  the  third  was  broken.  In 
four  cases  reduction  was  made. 

Dislocation  upward  may  be  complete  or  incomplete,  and  sometimes 
the  whole  or  part  of  the  first  cuneiform  remains  attached  to  the  first 
metatarsal  and  is  displaced  with  it.  Hitzig  collected  eleven  cases. 
The  most  frequent  cause  is  direct  violence,  but  in  two  cases  it  was  mus- 
cular action,  the  efforts  of  the  patients  to  avoid  falling  after  having 
slipped  while  carrying  heavy  bundles.  The  autopsies  and  the  com- 
pound cases  have  shown  rupture  of  the  dorsal  and  of  some  of  the 
palmar  ligaments,  rupture  and  laceration  of  some  of  the  interosseous 
ligaments  and  mnscles,  fracture  of  some  of  the  metatarsal  bones  and 
occasionally  of  the  cuboid  and  first  cuneiform,  and  sometimes  separa- 
tion of  the  first  or  fifth  metatarsal  laterally  from  the  others.  The 
metatarsus  may  remain  in  line  with  the  rest  of  the  foot  or  be  deviated 
to  either  side,  and  the  bases  of  its  bones  form  a  transverse  ridge  either 
corresponding  exactly  to  the  line  of  the  joints  or  at  a  somewhat  higher 
point  upon  the  tarsus.  Reduction  was  made  more  or  less  completely 
in  some  of  the  cases  ;  in  others  it  failed,  but  the  patients  gradually 
recovered  the  use  of  the  limb  ;  in  one  compound  case,  Mazot,  primary 
amputation  was  done. 

SUBLUXATION  OF  THE  HEAD  OF  A  METATARSAL  BONE. 

In  the  severest  form  of  this  affection,  first  described  by  Dr.  T,  G. 
Morton,^  the  head  of  the  fourth  metatarsal — less  frequently  the  third 
— appears  to  be  displaced  from  its  normal  relations  with  the  adjoining 
one  on  each  side,  and  also  with  its  toe.  The  most  recent  paper  on  the 
subject,  one  which  contains  a  full  bibliography,  is  by  Jones  and 
Tubby  ;^  the  reader  is  referred  to  it  for  the  pathology,  symptoms,  and 
treatment.     It  seems  appropriate  here  to  refer  only  to  the  severe  form 

1  Smyly :  Dublin  Quarterly  Journal  of  the  Medical  Sciences,  1854,  vol.  xvii.  p.  317. 
2 Mignot-Danton  :  Arch.  gen.  de  Med.,  1866,  vol.  ii.  p.  405. 
'^  Desprfes :  Bull,  de  la  Soc.  Anatomique,  1878. 
*  Morton:  Amer.  Journ.  Med.  Sci.,  January,  1876. 

5 Jones  and  Tubby:  Metatarsalgia  or  Morton's  Disease,  Annals  of  Surgery, 
September,  1898, 


DISLOCATIONS  OF  THE  METATARSAL  BONES.  933 

in  which  excision  of  the  head  of  the  metatarsal  bone  or  of  the  entire 
joint  is  occasionally  necessary  for  relief. 

DISLOCATIONS  OF  THE  TOES. 

1.  Metatarsophalangeal  Dislocations. 

Dislocations  of  the  Great  Toe.  The  most  common  cause  is  a  fall 
upon  the  toe ;  among  the  less  frequent  are  the  act  of  kicking,  receiv- 
ing the  weight  of  the  body  upon  the  toe  alone  in  going  upstairs,  and 
violence  recived  upon  the  metatarsus.  The  injury  is  frequently  com- 
])0und.  The  dislocation  has  been  upward,  backward,  and  to  one  side, 
the  most  frequent  appearing  to  be  those  to  the  outer  side  and  back- 
ward, and  secondly  those  directly  backward ;  the  former  of  these  two 
is  almost  always  compound,  with  projection  of  the  head  of  the  meta- 
tarsal bone  through  the  wound  on  the  inner  and  lower  aspect  of  the 
joint.  Coexistent  sprain  or  subluxation  of  the  first  tarso-metatarsal 
joint  has  been  occasionally  noted.  If  the  lateral  displacement  is  wide 
the  flexor  tendon  may  slip  past  the  head  of  the  metatarsal  bone  and 
make  reduction  impossible  except  by  operation. 

Of  14  simple  cases  collated  by  Delorme  reduction  was  easily  made 
in  8  and  failed  in  4 ;  of  the  compound  cases  the  head  of  the  metatarsal 
bone  was  excised  in  5,  and  the  entire  bone  removed  in  3  ;  of  14  com- 
pound cases  in  which  the  attempt  to  reduce  was  made,  it  was  successful 
in  9.  The  means  employed  to  reduce  have  been  traction  and  direct 
pressure  upon  the  base  of  the  phalanx,  and  arthrotomy  in  some. 

Dislocations  of  the  Other  Toes.  Dislocation  of  the  four  outer,  the 
four  inner,  or  of  all  five  toes  together  has  been  reported  in  several 
cases,  the  direction  of  the  displacement  being  upward  and  backward 
or  directly  outward ;  in  the  latter  the  head  of  the  metatarsal  projected 
through  a  wound  and  had  to  be  excised  before  reduction  could  be  made. 

2.  Dislocations  of  the  Phalanges. 

With  one  exception,  the  second  phalanx  of  the  third  toe,  in  all  the 
cases  that  have  been  reported  the  dislocation  was  of  the  terminal  pha- 
lanx of  the  great  toe.  In  one  case  reduction  could  not  be  made ;  in 
another,  which  was  compound,  a  portion  of  the  bone  was  subsequently 
cast  off. 


INDEX  TO  FRACTURES. 


A 


Absorption  of  bone  after  fracture,  63, 

112,  132 
Acetabulum,  352 

floor,  353 

rim,  358 
Acromion,  234 

Age,  influence  of,  on  frequency,  20 
Albee's  bone  insert,  117 
Allis,  relaxation  of  fascia  lata,  382 
Ambulatory  treatment,  119 
Amputation,  127 
Anchylophobia,  122 
Aneurism  after  fracture  of  clavicle,  218 
Apophyses,  separation  of,  24 
Arrest  of  growth,  30,  79,  251,  330,  415, 
;     450 

Arteries,  injuries  of,  71,  81 
Ashhurst,  by  muscular  action,  44 

at  elbow,  288,  278 
Ashhurst  and  Newell,  femur,  140,  404 
Astragalus,  470 

Asymmetry,  normal,  of  limbs,  53 
Atlas,  168 
Atrophy,  interstitial,  41 

of  Umb,  80 
Axis,  168 


B 


Bardenheuer,  traction,  110 
Barker,  suture  of  patella,  433 
Barton's  fracture  of  the  radius,  332 
Bennett,  first  metacarpal,  342 
Blake's  spUnt,  409 
Bloodvessels,  injury  of,  71,  81 
Buck's  extension,  105,  404 
Burrell,  fracture  of  spine,  178 


Cabot  splint,  96 

Calcaneum,  471 

Callus,  exuberant,  64,  76 

formation  of,  59 

painful,  77 

retarding  influences  upon,  131 

softening  of,  79 

weak,  79 
Cancer  a  cause  of  fracture,  50 
Carpal  bones,  335 
Cartilages,  fracture  of  costal,  210 


Causes  of  fracture,  41 

determining,  42 

muscular  action,  43 
predisposing,  41 

acquired  tendency,  42 
cancer,  50 

congenital  tendencj^,  42 
disease  of  nerve-centres,  48 
inherited  tendency,  42 
osteomyelitis,  51 
rachitis,  49 
syphilis,  49 
Chaput,  patellar  disability,  436 
Chest,  discoloration  of  skin  by  compres- 
sion of,  208 
Clavicle,  214 

complications,  218,  222 

etiology,  220 

pathology,  214 

relations  to  dislocation  of  shoulder, 

626 
simultaneous  fracture  of  both,  223 
symptoms  and  course,  221 
treatment,  223 
Clinical  coui'se,  66 
Coccyx,  355 
Colles's  fracture,  320 
Comminuted  fractures,  28 
Comphcations  of  fracture,  70 
early  local,  70 

general,  73 
late  local,  76 
Compound  fractures,  32,  63 

treatment,  124 
Compression  fracture,  28 
Condyloid   process   of  inferior   maxilla, 

188,  189,  194 
Coracoid,  235 
Coronoid  process  of  inferior  maxilla,  188 

of  ulna,  304 
Crepitus,  55 
Croux's  paste,  103 
Cubitus  valgus,  285 

varus,  263,  274,  278,  283 
Cuboid,  477 
Cuneiform,  carpal,  341 
tarsal,  478 


Darin's  solution,  126 
Dandridgo,  fracture  of  spine,  178 
Deformity  a  symptom,  53 
disappearance  of,  280 

(935) 


936 


INDEX  TO  FRACTURES 


Delbet  splint,  406 

Delirium,  75 

Depressions,  24 

Diacondylar,  of  humerus,  269,  277,  291 

Diagnosis,  53 

Displacements,  37 

DoUinger,  neck  of  femur,  393 

Dressings,  permanent,  103 

temporary,  92 
Dysphagia  valsalviana,  195,  564 


E 


Embolism,  81 

fat,  74 
Ensiform  appendix,  201 
Epiphysis,  separation  of,  29 

repair  of,  65 
Epitrochlea,  280 
Etiology,  41 
Extracapsular,  of  femur,  363,  370,  376 


Failtjke  of  union,  66,  130 
etiology,  131 
treatment,  134 
Femoral  artery,  torn,  401 

vein,  torn,  401 
Femur,  360 

absorption  of  neck,  376 

angle  of  neck,  362 

fractures  at  the  lower  end,  410 

external       tuberosity, 

419 
intercondyloid,  410 
internal      epicondyle, 

418 
of  either  condyle,  416 
separation  of  epiphy- 
sis, 413 
at  the  upper  end,  361 

of    great    trochanter, 

397 
of    small     trochanter, 

398 
of  the  head,  361 
of  the  neck,  361 

bony  union  after, 

375 
causes,  365 
classification,  363 
diagnosis,  388 
excision  of  head, 

394 
fixation   of   head, 

394 
impaction,  373 
inversion  in,  374, 

381 
pathology,  366 
at     base     of 
neck,  370 


Femur,  fractures  at   the  upper  end   of 

the     neck, 
patholog  y, 
through  the 
neck,  366 
separation  of 
epiphysis, 
368 
prognosis,  386 
repair,  375 
symptoms,  380 
treatment,  388 
through  great  trochan- 
ter and  neck,  394 
of  the  shaft,  398       ' 

failure  of  union,  410 
prognosis,  403 
symptoms,  402 
treatment,  404 

in  children,  408 
Fenestrated  sphnts,  104,  124 
Fibula,  468 
Fingers,  344 
Fissures,  23 
Fixation,  direct.  111 

by  plating,  114 
Foot,  470 
Forearm,  296 

at  the  elbow,  296 

coronoid  process,  304 
head  of  radius,  306 
neck  of  radius,  309 
olecranon,  296 
at  the  wrist,  310 
CoUes's,  320 
other  than  CoUes's,  332 
of  the  shaft,  310 

both  bones,  310,  334 
radius,  319 
ulna,  317 
Fractura  diacondylica,  268,  277,  291 


G 


Gangrene,  72 
Gas  bacillus,  74 
Glenoid,  240 
Green-stick  fractures,  23 
Growth,  arrest  of,  30,  79,  251,  330,  415, 
450 

exaggeration  of,  79 
Gunshot  fractures,  126 
Gunstock  deformity  of  elbow,  263,  274. 

278,  283 
Gurlt,  muscular  action,  44 

statistics,  age,  20 

syphihtic,  49 

tumor,  50 
Gutters,  wire,  94 


H 

Hawley's  loop,  113 
Hsematomyelia,  166,  168 


INDEX  TO  PRACTVRES 


937 


Heart  wound  in  injury  of  chest,  202,  206 

Hemorrhage,  71 

Hennequin's  spHnt  for  arm,  259 

for  femur,  392 
Hodgen's  sphnt,  106 
Hudson  Street  Hospital  statistics,  com- 
pound fractures,  33 
general,  19 
humerus,  19 
season,  21 
Humerus,  241 

lower  end,  266 

above  the  condyles,  265 
articular  process,  290 
capitellum,  291 
development  of  epiphysis, 

266,  289 
diagnosis,  293 
epitrochlea,  280 
external  condyle,  284 

epicondyle,  282 
intercondyloid  fracture,  288 
internal  condyle,  282 
separation  of  epiphysis,  289 
tardy  paralysis,  294 
trochlea,  292 
treatment,  277,  294 
shaft,  260 
upper  end,  241 

anatomical  neck  and  tuber- 
osities, 242 
head,  242 

separation  of  epiphysis,  248 
surgical  neck,  252 

symptoms,  255 
treatment,  257 
tuberosities,  246 
Hyoid  bone,  195 


Ilium,  356 

Immobilization  of  joints,  121 
Incomplete  fractures,  23 
Inherited  tendency  to  fracture,  42 
Intra-articular  fracture,  31 

repair  of,  64 
Intra-capsular  of  femur,  343,  366,  378 
Intra-uterine,  51 
Ischajmic  contraction,  72 
Ischium,  357 


Joints,  management  of,  121 

stiffness  of,  79 
Jugular  vein  torn  in  fracture  of  clavicle, 
219 


KiNGSLEY,  interdental  splint,  190 
Kocher,  anatomical  neck  of  humerus,  243 

capitellum,  291 

femoral  neck,  364,  369,  395 


Kocher,  femoral  neck,  upper  epiphysis, 

369 
Konig,  disappearance  of  deformity,  280 

neck  of  femur,  394 

operative  fixation,  85 


Lane,  fracture  of  coracoid,  235 
of  first  rib,  205 
operative  fixation,  85,  113 
Larynx,  197 
Leg,  fractures  of,  488 
fibula,  468 
lower  end,  447 

by  eversion,  450 
by  inversion,  463 
comminuted,  448 
anterior     portion     of 

tibia,    466 
posterior    portion    of 

tibia,  466 
separation  of  epiphy- 
sis of  fibula,  469 
of  tibia,  449 
supramalleolar,  448 
shaft,  444 
upper  end,  438 

epiphysis  of  fibula,  468 

of  tibia,  442 
spine  of  tibia,  443 
tubercle  of  tibia,  443 
Leucocytosis,  67 
Liability,  inherited,  42 
Ligamentum  patellae,  retraction,  422 
Longitudinal  fractures,  27 
Lumbar  puncture  in  diagnosis,  156 
Lung,  hernia  of,  208,  598 

injured,  in  fracture  of  clavicle,  219 
of  ribs,  206 


M 


Magnuson's  plate,  117 
Malar  bone,  182 
Malgaigne's  hooks,  430 
Marsh,  fracture  of  first  rib,  205 
Massage,  118 
Matas's  sphnt,  192 
Mayor's  scarf  for  clavicle,  225 
Maxilla,  inferior,  187 

condyloid  process,  188,  189,  194 

coronoid  process,  188 

treatment,  192 
superior,  184 
Metacarpal  bones,  342 
Metatarsal  bones,  478 
Mobility,  abnormal,  54 
Moulded  splints,  99 
Multiple  fractures,  31 
Mumford,  coinj)ound  fractures,  33 
Muscles,  atrophy  of,  80 
degeneration  of,  72 
Muscular  action  a  cause  of  fracture,  43 
Musculo-spiral  nerve,  78,  255,  265 


938 


INDEX  TO  FRACTURES 


N 


Necrosis,  63 

Nerve  disease  a  cause  of  fracture,  48 

inclusion  in  callus,  78 
injury  of,  78 

Nose,  180 


Oblique  fractures,  25,  26 
Olecranon,  296 

epiphysis,  303 
Operative  fixation,  108,  111 

reduction,  85 
Os  magnum,  341 
Osteomyelitis  a  cause,  51 


Pain  a  symptom,  57 

Paralysis  a  result  of  fracture,  78 

its  effect  on  repair,  133 
Parkhill's  clamp,  113 
Patella,  420 

causes,  420 

course  and  terminations,  424 

disability  after  fracture,  423,  436 

pathology,  421 

refracture,  423,  437 

symptoms,  423 

treatment,  426 

non-operative,  428 
operative,  431 
Pathological  fractures,  47 
Pathology  of  fracture,  22,  59 
Pelvis,  346 

acetabulum,  352,  358 

coccyx,  355 

double  vertical  fracture,  349 

Uium,  356 

ischium,  357 

lateral  portion  of  ring,  349 

pubic  portion  of  ring,  349 

pubis,  358 

sacrum,  354 

separation  in  front  and  behind,  348 
of  all  three  joints,  348 
of  pubic  symphysis,  347 
of  sacro-iliac  symphysis,  348 
Periosteal  bridge,  39,  60 

fringe,  423,  431 
Periosteum,  extent  of  injury,  59 

share  in  repair,  60 
Phalanges,  344,  479 
Pisiform,  341 

Plane,  double  inclined,  110 
Plaster  of  Paris,  97,  99 
Plating,  114 
Pneumonia,  76 

Poland,  epiphysis  of  fibula,  469 
of  humerus,  290 
of  tibia,  442 

trochanter,  397 
Pott's  fracture  at  ankle,  450 


I  Pouteau,  fracture  of  radius,  320 
Prognosis,  general,  138 
Pseudarthrosis,  130 

causes,  131 

symptoms,  133 

treatment,  134 
Pubis,  358 

separation  of,  347 


R 


Rachitis  a  cause,  49 
Radius,  CoUes's  fracture,  320 

fractures  at  wrist  other  than  CoUes's, 
332 

longitudinal,  334 

of  head,  306 

of  neck,  309 

of  shaft,  319 

styloid  process,  334 
Reduction,  83 
Repair,  59 

of  cartilage,  64,  212 
opposing  influences,  131 
Results,  statistics,  39 
Retention,  90 
Rheumatism  a  cause,  49 
Ribs,  205 

Roberts,  fracture  of  radius,  334 
Robson,  suture  of  patella,  430 
Roentgen  rays  in  diagnosis,  56 


Sacro-iliac  synchrondrosis,  348 
Sacrum,  transverse  fracture,  354 

vertical  fracture,  349 
Sarcoma  after  fracture,  77 
Sayre,  dressing  for  clavicle,  226 
Scaphoid,  carpal,  336 

tarsal,  476 
Scapula,  230 

acromion,  234 

body,  230 

coracoid  process,  235 

glenoid  ca^dtJ^,  240 

inferior  angle,  233 

neck,  236 

spine,  234 

upper  angle,  233 
Schanz,  old,  of  patella,  437 
Season,  influence  of,  21 
Secondary  fracture,  79 
Semilunar,  340 
Separation  of  epiph5fsis,  29 
Septicaemia,  73 
Sesamoid,  345,  479 
Skin,  injury  of,  40,  70 

stained  by  compression  of  chest,  208 
Skull,  142 

mechanism  and  patholog}^  145 

pathological    and    reparative    pro- 
cesses, 151 

symptoms  and  treatment,  152 


INDEX  TO  FRACTURES 


939 


Skull,  symptoms  and  treatment,  circum- 
scribed, of  vault,  153 
fissured,  with  brain  injury, 

155 
internal  table,  149,  158 
perforation  of  base,  160 
rupture  of  middle  menin- 
geal, 158 
Smith's  anterior  spUnt,  95 
Spine,  162.     {See  Vertebrae.) 
Spiral  fractures,  26 
Splinters,  vitahty  of,  64 
SpHnts,  92 

long  side,  110 
plaster-of-Paris,  99 
suspended,  95 
Spontaneous  fractures,  47 
Sprain-fracture,  22 
Statistics,  compound  fractures,  33 
epiphyses,  29 
general,  19,  139 
influence  of  age,  20 
season,  21 
syphilis,  49 
tumor,  50 
muscular  action,  44 
prognosis,  139 
Steinmann's  nails,  106 
Sternum,  199 
Stiffness  of  joints,  79 
Stocking  splint,  100 
Stromeyer's  cushion,  264 
Subclavian    artery    and    vein    torn    in 

fracture  of  clavicle,  219 
Subjective  symptoms,  57 
history,  57 
loss  of  function,  57 
pain,  57 
Suppuration  after  fracture,  73 
Supracondyloid  of  humerus,  265 
Supramalleolar  fracture,  448 
Suspended  splints,  95 
Suspension  and  elevation,  100 
Sustentaculum  tali,  474,  921 
Suture  of  bones.  111 
Symphysis  pubis,  separation,  347 
Symptoms,  53 

objective  signs,  53 

abnormal  mobility,  54 
crepitus,  55 
deformity,  53 
subjective,  57 
Syphilis  a  cause,  49 


Tetanus,  75 

Thomas,  head  of  radius,  306 
Thorborn,  fracture  of  spine,  179 
Thrombosis,  71,  81 
Ti})ia,  438.     (See  Leg.) 
Tibial  artery,  torn,  445 
Toes,  429 
Trachea,  198 

Traction  by  suspension,  106 
by  weight  and  pulley,  105 


Traction,  continuous,  105 
with  suspension,  108 

Transverse  fractures,  26 

Trapezium,  341 

Treatment,  82 

ambulatory,  119 

by  amputation,  127 

by  operation,  85,  111 

of  compound  fractures,  123 

articular,  128 
of  gunshot  fractures,  126 
of  pseudarthrosis,  134 
of  vicious  union,  136 

Trochanter  major,  397 
minor,  398 


Ulna,  coronoid  process,  304 
olecranon,  296 
shaft,  317 
styloid  process,  334 
Ulnar  nerve,  injury  of,  280 
Unciform,  341 

Union,  deformed  or  faulty,  136 
delayed,  or  failure  of,  130 
fibrous,  130 


V-SHAPED  fractures,  27 
Varieties,  22 

of  direction,  25 
of  seat,  29 
Velpeau,  dressing  for  clavicle,  226 
Vertebrae,  162 

course  and  terminations,  173 
etiology,  166 
pathology,  163 
arches,  164 
bodies,  163 
cord,  165 
processes,  165 
symptoms,  167 

atlas  and  axis,  168 
lower  cervical  and  upper  dorsal, 
170 
dorsal  and  upper  lumbar, 

172 
lumbar,  173 
treatment,  176 
Vertical  suspension,  109,  289,  408 
Volkmann's  foot-rest,  105 
ischaemic  contraction,  72 
splint,  94 

suture  of  patella,  436 
Von  Bergmann,  of  orbital  plate,  149 
old  fracture  of  patella,  437 


Zygoma,  182 


INDEX  TO  DISLOCATIONS. 


Accidents  during  reduction,  527 
Acetabulum,  fracture  of  edge,  822 

of  floor,  851 
Acromion,  fracture  of,  632,  673 
After-treatment,  525 
Age,  influence  of,  486 
Ambi,  519 

Anaesthesia,  dangers  of,  517 
Aneurism  after  dislocation,  495 
Ankle,  congenital  dislocations  of,  928 

dislocations  at  or  near,  905 
Annandale,  meniscus,  of  knee,  882 

recurrent,  of  jaw,  563 
Anterior  oblique  dislocation  of  hip,  828 
Arteries  injured  in  dislocation,  494 

in  reduction,  524,  529 
Arthrotomy  to  reduce,  523 
Astragalus,  dislocation  of,  906 

"total"  dislocation  of,  919 
Atlas,  dislocation  of,  578 
Avulsion  of  arm,  529 
Axillary  artery  injured  in  dislocation,  495 
in  reduction,  524,  531 


B 


Harwell,  astragalus,  922 
Bigelow,  hip,  classification,  814 

reduction,  515,  830,  837 
Birth  palsy,  690 
Bloodvessels  injured  in  dislocation,  494 

during  reduction,  529 
Bone,  overgrowth,  after  dislocation,  505 
Brachial  artery  injured  in  dislocation,  496 
plexus  injured,  674 

torn  in  reduction,  535 
Brachialis  anticus,  ossified,  706 
Brickner,  subluxation  of  shoulder,  694 
Broca,  subastragaloid,  912 
Burrell,  recurrent,  of  shoulder,  680 
Busch,  obstacles  to  reduction,  515 


Calcaneum,  dislocation  of,  929 
Caldwell,  rupture  of  circumflex,  530 
Capsule  an  olistacle,  516 

lesions  of,  492 
Carpal  bones,  dislocation  of,  776,  782 
Carpo-metacarpal  dislocations,  787 


Causes,  determining,  489 

predisposing,  488 
Circumflex  artery  injured  in  dislocation, 
495,  531 
nerve  injured  in  dislocation,  497,  673 
Clavicle,  dislocations  of,  602 
acromial  end,  610 

subacromial,  616 
subcoracoid,  619 
supra-acromial,  611 
both  ends,  619 
sternal  end,  602 

backward,  606 
forward,  603 
habitual,  606 
upward,  608 
Coccyx,  dislocations  of,  804 
Comphcations  {see  also  Special  Disloca- 
tions), 493 
of  bloodvessels,  494 
of  bones,  493 
of  nerves,  496 
of  soft  parts  and  skin,  499 
of  viscera,  499 
Compound  dislocations,  499 
Congenital  dislocations  {see  also  Special 
Dislocations),  541 
at  hip,  pathology,  546 
statistics,  541 
symptoms,  549 
treatment,  551 
at  shoulder,  686 
etiology,  530 
Consecutive  reduction,  515 
Coracoid  process,  fracture  of,  673,  668 
Coronoid  process  of  ulna,   fracture  of, 

703,  718,  728 
Costal  cartilages,  dislocations  of,  599 
Course,  513 

Cras,  injuries  of  vessels,  530 
Crural  nerve  pressed  on  in  dislocation, 

499 
Cuboid,  dislocation,  930 
Cuneiform  bones,  dislocation  of,  930 


Death  by  anaesthetic,  517,  540 

sudden,  after  reduction,  540 
Definitions,  483 

D(>!2;c'nc'rati<in  after  dislocation,  507 
Desi)res,  method  of,  521 
Diagnosis,  508 

(-941) 


942 


INDEX  TO  DISLOCATIONS 


Distention,  dislocation  by,  554 
Divergent  dislocation  of  radius  and  ulna, 

727 
Dollinger,  old,  of  elbow,  758 

of  hip,  819,  860 

of  shoulder,  672,  684 
Dorfler,  radius,  with  fracture  of  ulna,  751 
Dubreuil,  habitual  dislocation,  526 
Duverney,  radius,  by  elongation,  746 
Dysphagia  valsaviana,  564 


E 


Elastic  traction,  522 
Elbow,  anatomy  of,  695 

dislocations  of  {see  also  Radius  and 
Ulna),  695 
backward  dislocations,  698 
after-treatment,  710 
compUcations,  496,  497, 702 
diagnosis,  704 
pathology,  700 
prognosis,  705 
symptoms,  703 
theories  of  production,  698 
treatment,  706 
classification,  697 
congenital  and  pathological,  759 
divergent,  of  radius  and  ulna, 

727 
forward  dislocations,  721 
frequency,  697 
injury  of  nerves  in,  497,  703 

of  vessels  in,  496,  497 
isolated,  of  radius,  734 

of  ulna,  730 
lateral,  710 

complete  outward,  717 
subepicondylar,  720 
supra-epicondylar,  720 
incomplete,  711 
inward,  712 
outward,  714 
old  unreduced,  treatment,  753 

relations  to  dislocations  of 
shoulder  and  fracture  of 
clavicle,  626 
Embolism,  fat,  540 

fatal,  540 
Emphysema  during  reduction  of  shoul- 
der, 528,  535 
Ensiform  process,  dislocation  of,  596 
Epitrochlea,  fracture  of,  700,  715,  728, 

755 
Erecta,  luxatio,  656 
Etiology,  488 
Everted  dorsal  dislocation  of  hip,  825 


Farabettf,  anatomy  of  shoulder,  623 
reduction  of  shoulder,  649 
subtricipital,  657 
thumb,  793 


Fat  embolism,  540 

Femoral  artery,  injured,  496,  852 

vein,  injured,  842,  852 
Femur,  fracture  of  head,  822,  853 

of  neck,  853 

of  shaft,  836,  854 
Fibula,  dislocations  of,  901 

lower  end,  903 

spontaneous  and  pathological, 
903 

upper  end,  901 
Fingers,  dislocations  of,  793 

distal  phalanges,  802 

metacarpo-phalangeal,  799 

of  middle  phalanges,  801 
Flaubert,  rupture  of  brachial  plexus,  528, 

535 
Flower,  classification,  shoulder,  628 
Foot,  dislocations  of,  906 

backward,  906 

compound,  911 

congenital,  928 

forward,  908 

inward,  909 

outward,  910 

upward,  911 
Forearm,  avulsion  of,  529 
Fracture  as  a  comphcation,  493 
during  reduction,  537 


G 


Gangrene,  502,  538 
Gelle,  obstacles  to  reduction,  515,  830 
Glenoid  fossa,  fracture  of,  673 
Grawitz,  congenital,  of  hip,  545 
Gunn,  obstacles  to  reduction,  515,  830 


H 


Habitual  dislocations,  490,  526 
of  hip,  857 

of  shoulder,  491,  501,  678 
treatment,  526 
Hsematomyelia,  164,  168,  571 
Hahn,  lateral,  of  elbow,  711 
Hip,  anatomy  of,  807 

dislocations  of,  807-864 

accidents  in  reduction,  856 
after-treatment,  857 
backward  dislocations,  817 

anterior  oblique,  828 
dorsal,  818 

pathology,  819 
symptoms,  822 
everted  dorsal,  825  - 
treatment,  829 
central,  352,  851 
classification,  813 
complications,  852 
compound,  811 
congenital,  546 
directly  upward,  845 
downward  and  inward,  834 


INDEX   TO  DISLOCATIONS 


943 


Hip,   dislocation  of,  downward  and  in- 
ward, obturator,  834 
perineal,  839 
on  tuberosity  of  ischi- 
um, 849 
fracture  during  reduction,  856 
of  acetabulum,   352,   820, 

835 
of  femur,  853,  854 
habitual  dislocations,  857 
ileo-pectineal,  840 
infracotyloid,  849 
injury  of  nerves  in,  537,  842,  853 
of  vessels  in,  496,  842,  852 
intrapelvic,  840,  844 
labrum  cartilagineum,   detach- 
ment of,  822,  855 
old  dislocations,  treatment  of, 
859 
arthrotomy,  860 
excision,  861 
osteotomy,  861 
paralytic  dislocations,  863 
pathological  dislocations,  862 
prognosis,  857 

simultaneous,  of  both  hips,  855 
spontaneous  dislocations,  862 
statistics,  810 
subspinous,  845 
supracotyloidea,  845 
suprapubic,  840 
through  acetabulum,  352,  851 
upward,  845 

and  forward  (suprapubic), 
840 
Honigschmied,  tibio-tarsal,  906 
Hudson  Street  Hospital  statistics,  485 
Hueter,  outward,  elbow,  715 
Hyoid  bone,  504 


Ileo-pectineal  dislocation  of  hip,  840 
India-rubber,  traction  by,  522 
Infracotyloid  dislocation  of  hip,  849 
Internal  derangement  of  knee,  881 
Intracoracoid  dislocation  of  shoulder,  639 
Intrapelvic  dislocation  of  hip,  840 
Irregular  dislocations,  516 
Isemeyer,  pathological,  of  patella,  899 


Jaw,  dislocation  of  lower,  557 
backward,  557 

with  fracture,  557 
congenital,  563 
forward,  558 
outward,  558 
pathological,  563 
upward,  558 

Jossel,  recurrent,  of  shoulder,  501 
subglenoid,  656 


Kammerer,  fracture  of  femur,  855 
Knee,  dislocations  of,  865 
antero-lateral,  877 
backward,  871 
by  rotation,  878 
congenital,  884 
forward,  867 
injuries  of  nerves  in,  869 

of  vessels  in,  495,  869,  872 
lateral,  874 

inward,  877 
outward,  874 
spontaneous  and  pathological, 

886 
statistics,  866 
internal  derangement,  881 
semilunar  cartilages,  881 
Kocher  on  reduction  of  hip,  831,  838,  845 

of  shoulder,  647 
Korte,  injuries  of  vessels,  530 
Kronlein,  statistics,  congenital,  542 
elbow,  697 
general,  486 


Labrum  cartilagineum,  detachment  of, 

822,  855 
Lobker,  habitual,  of  shoulder,  679 

of  radius,  743 
Lorenz,  congenital,  of  hip,  552 


M 


Madelung,  spontaneous,  of  wrist,  772 
Malgaigne,  classification,  hip,  814 

shoulder,  627 

radius,  with  fracture  of  ulna, 
-     751 
Manipulation,  reduction  by,  521 

at  hip,  829 

at  shoulder,  647 
Marchand,  accidents  in  reduction,  518, 

530 
McBurney's  hook,  672 
Mears,  old,  of  shoulder,  683 
Median  nerve,  injury  of,  497 
Medio-carpal  dislocations,  777 
Medio-tarsal  dislocations,  927 
Metacarpal  bones,  787 
Metacarpo-phalangeal     dislocations     of 
fingers,  799 

of  thumb,  793 
Metatarsal  bones,  dislocations  of,  931 

subluxation  of  head,  932 
Metatarso-phalangcal  dislocations,  933 
Midcarpal  fracture-dislocation,  778 
Morton,  metatarsalgia,  932 
Muscles  torn  during  reduction,  529 
Muscular  action  a  cause  of  dislocation, 

489 
Musculo-spiral  nerve  torn,  703,  752 


944 


INDEX  TO  DISLOCATIONS 


Myers,  congenital,  of  hip,  551 
Myopathic  dislocations,  555 
Myositis  ossificans,  706 


N 


Nerves,  injured,  496,  532,  535,  703,  752, 

842,  850,  869 
Nicoladoni,  old,  of  elbow,  755 


Obstetrical  paralysis,  685,  690 
Obturator,  dislocation  of,  834 
Occiput,  dislocation  of,  576 
(Edema,  persistent,  507,  539 
Old  dislocations,  pathology,  503 

treatment,  523 
Olecranon,  fracture  of,  702,  723 
Os  magnum,  dislocation  of,  786,  787 


Paci,  congenital,  of  hip,  552 

Paralysis  after  dislocation  of  shoulder, 

497,  536,  679 
Paralytic  dislocations,  555 

of  hip,  863 

of  shoulder,  690,  692 
Patella,  dislocations,  887 

complete  reversal,  896 

congenital,  898 

downward,  with  rotation,  897 

edgewise  or  vertical,  894,  896 

habitual  or  pathological,  899 

inward,  895 

outward,  890 
Pathological  dislocations,  553 
Pathology  of  old  dislocations,  503 

of  recent  dislocations,  492 
Pelvis,  dislocations  of,  804 
Pendel-methode,  at  shoulder,  644 
Perineal  dislocations,  839 
Petit,  principle  of  reduction,  520 
Phalanges  of  foot,  dislocations  of,  933 
of  hand,  dislocations  of,  793 
distal,  802 
middle,  801 
proximal,  793,  799 
Pingaud,  radius,  by  elongation,  748 
PioUet,  old,  of  hip,  859 
Pisiform,  dislocations  of,  785 
Poinsot,  subastragaloid,  912 
Pophteal  artery  torn,  495 
Pouteau  on  reduction  of  hip,  520 
Prognosis,  513 
Pubic,  of  hip,  840 


Radio-carpal  dislocations,  765 
backward,  767 


Radio-carpal    dislocations,     congenital, 
775 
forward,  769 
outward,  771 
pathological,  771 
subluxation,  771 
Radio-ulnar  joint,  lower,  763 
backward,  763 
forward,  764 

inward  and  downward,  765 
Radius,  head  broken,  703 

isolated  dislocations  of,  734 
backward,  735 
by  elongation,  746 
forward,  742 
outward,  740 

pathological  and   congeni- 
tal, 5  6,  759 
with  fracture  of  ulna,  751 
Recurrent  dislocations,  490 
Reduction,  515 

accidents  during,  524,  527 
by  manipulation,  521 
methods  of,  518 
obstacles  to,  515 
spontaneous,  515 
Repair,  500 

Retro-axillary  dislocation,  663 
Rheumatism,  dislocation  in,  554 
Ribs,  broken,  499 

dislocations,  597 
Ricard,  habitual,  of  shoulder,  526,  681 
Ross,  sublux,  shoulder,  694 


Scaphoid,  dislocations  of  carpal,  782 

of  tarsal,  929 
Schinzinger,  reduction  of  shoulder,  650 
Sciatic  nerve,  pressure  upon,  821,  853 
Scudder,  compound,  of  foot,  911 
Semilunar  bone,  dislocation  of,  783 

cartilages,  dislocation  of,  881 
Shoulder,  anatomy  of,  621 
dislocations  of,  621-694 
anterior,  631 

after-treatment,  651,  676 
by  muscular  action,  490 
intra-coracoid,  639 
subcoracoid,  632 
pathology,  634 
symptoms,  637 
treatment,  641 

accidents  during,  524, 

527 
by  manipulation,  647 
Kocher,  647 
Schinzinger,  650 
direct  reposition,  643 
heel  in  axilla,  646 
traction  downward,  643 

upward,  645 
with  leverage,  646 
birth,  685 
classification,  626 


INDEX  TO  DISLOCATIONS 


945 


Shoulder,  dislocations  of,  complications, 
669 
fracture  of  acromion,  632, 
673 
of  coracoid,  668,  673 
of  glenoid  fossa,  673 
of  neck,  670 
of  shaft,  673 
of  tuberosity,  660,  670 
injury  of  nerves,  497,  535, 
673 
of  vessels,  496,  529 
compound  dislocations,  675 
congenital  dislocations,  686 
downward  dislocations,  653 
luxatio  erecta,  656 
subglenoid,  653 
subtricipital,  657 
habitual,  491,  501,  678 
injury  of  nerves  in,  497,  535,  673 

of  vessels  in,  496,  529 
old,  treatment,  683 
paralytic,  692 
pathological,  693 
posterior,  658 

of  infancy,  690 
symptoms,  662 
treatment,  664 
prognosis,  676 
recurrent,  491,  501,  678 
relation  to  other  injuries,  626 
retro-axiUary,  663 
simultaneous,  of  both  shoulders, 

659,  665,  675 
statistics,  625 
subacromial,  658 
subluxation,  693 

of  infancy,  690 
subspinous,  658 
upward  (supracoracoid),  664 
Skin  torn  during  reduction,  528 
Smith,   Nathan,   on  manipulation,   521, 

829 
Spinal  colunm  (see  Vertebrae),  565 
Spontaneous  dislocations,  553 

reduction,  515 
Sprengel,  lateral,  elbow,  711,  714 
Statistics,  congenital,  541 

death  by  anaesthetic,  518 
general,  485 
influence  of  age,  487 
of  paralysis,  497 
injury  of  vessels,  529,  530 
Sternum,  dislocations  of  body,  592 

of  ensiform  process,  596 
Streubel,  lateral,  elbow,  711 
obstacles  to  reduction,  515 
patella,  888 
radius  alone,  736 

by  elongation,  747 
Subacromial  dislocation  of  clavicle,  616 

of  shoulder,  658 
Subastragaloid  dislocations,  912 
Subclavicular,  of  shoulder,  639 
Subcoracoid,  of  clavicle,  619 
of  shoulder,  632 
60 


Subepicondylar  dislocation,  720 
Subglenoid  dislocation,  653 
Subscapular  atery  torn,  529,  532,  655 
Subspinous  dislocation  of  hip,  845 

of  shoulder,  658 
Subtricipital  dislocation,  657 
Suppuration,  518,  538 
Supra-acromial    dislocation   of    clavicle, 

611 
Supracoracoid    dislocation    of   shoulder, 

664 
Supracotyloid  dislocation  of  hip,  845 
Supra-epicondylar  dislocation,  720 
Supraglenoid,  shoulder,  664 
Suprapubic  dislocation,  840 
Sus-cotyloidienne  dislocation,  845 
Symptoms,  508 
Syncope,  540 


Tarsal  bones,  dislocation  of,  929 
Thomas,  habitual  dislocation,  of  shoul- 
der, 678,  682 
posterior,  of  infancy,  690 
Thumb,  dislocations  of,  793 
backward,  794 
forward,  798 
lateral,  799 
distal  phalanx,  802 
proximal  phalanx,  793 
Thyroid  dislocation,  834 
Tibio-tarsal  dislocation,  906 
Tillmanns,  lower  radio-ulnar,  763 

radio-carpal,  766 
Toes,  dislocation  of,  933 
Traction  by  gravity,  523 

elastic,  522 
Trapezium,  dislocation  of,  787 
Trapezoid,  dislocation  of,  786,  787 
Treatment,  515 

Trendelenburg,  old,  of  elbow,  755 
Tuberosity  of  humerus,  broken,  660,  661, 
670 


Ulna,  fracture  with  dislocation  of  radius, 
751 
isolated  dislocation  of,  730 
backward,  731 
forward,  734 
inward,  734 
lower  end,  763 
Ulnar  artery  torn,  497 

nerve  injured,  497,  724 
Unciform,  dislocation  of,  785 


Vedova,  patella,  900 
Verneuil,  congenital,  544 
Vertebrae,  dislocations  of,  565 

atlas,  578 

cervical,  576 


946 


INDEX  TO  DISLOCATIONS 


Vertebrae,   dislocations  of,  classification, 
566 

dorsal,  588 

etiology,  572 

lumbar,  589 

occiput,  576 

pathology,  566 

prognosis,  574 

secondary  changes,  571 

symptoms,  572 

treatment,  575 
Viscera,  injury  to,  499 
Volkmann,  pathological,  554 
Voluntary  dislocations,  555 
Von  Ammon,  congenital,  545 


W 


Warbasse,  congenital,  of  hip,  551 
Wippermann,  fracture  of  neck  of  femur, 

853 
Wrist,  dislocations  at,-  763 
pathological,  771 


ZiELEWicz,  congenital,  of  patella,  898 


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